NHTSA 1105 ATT C1 NCRUSS Daily Site--Tallies

ATTACHMENT C1

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-0642. Since data will be collected on this form via observation, public reporting for this collection of information is estimated to be approximately 0 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590. NHTSA Form 1105

		United States Department of Transportation National Highway Traffic Safety Administration		DAILY SITE FORM TALLIES (3/10/11 Draft)		Form Approved O.M.B. No. 2127-0642 Expiration Date: xxxx National Automotive Sampling System National Child Restraint Use – Special Study
Interviewer: ___________________________________________ Observer: _______________________________________________ PSU: __________________________________ Site ID: _________________________________ Area: 1. O Urban, 2. O Suburban, 3. O Rural Spanish Speaker Available: 1. O No 2. O Yes, all day 3. O Yes, partial day Zip Code ___ ___ ___ ___ ___
	PERIODS				TALLIES OF LIGHT VEHICLES WITH CHILDREN <9 YEARS (By Hour)			TALLIES OF CHILDREN <9 YEARS INSIDE THE VEHICLES (By Hour)
	Date: _______/_______/2011 Time: ____ ____ : ____ ____ Temperature: ____________ Weather: 1.  Clear 2.  Cloudy, 3.  Fog, 4.  Rain 5.  Sleet 6.  Snow
	Date: _______/_______/2011 Time: ____ ____ : ____ ____ Temperature: ____________ Weather: 1.  Clear 2.  Cloudy, 3.  Fog, 4.  Rain 5. Sleet 6.  Snow
	Date: _______/_______/2011 Time: ____ ____ : ____ ___ Temperature: ___________ Weather: 1.  Clear 2.  Cloudy, 3.  Fog, 4.  Rain 5.  Sleet 6.  Snow
			NOTES