NHTSA 1105 ATT C1 NCRUSS Daily Site--Tallies

National Child Restraint Use Special Study (NCRUSS)

ATT C1-NCRUSS 3-10-11 Daily Site-Tallies

National Child Restraint Use Special Study (NCRUSS)

OMB: 2127-0642

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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



  1. Interviewer: ___________________________________________

  2. Observer: _______________________________________________

  3. PSU: __________________________________

  4. Site ID: _________________________________

  5. Area: 1. O Urban, 2. O Suburban, 3. O Rural

  6. Spanish Speaker Available: 1. O No 2. O Yes, all day 3. O Yes, partial day

  7. Zip Code ___ ___ ___ ___ ___



  1. PERIODS


  1. TALLIES OF LIGHT VEHICLES WITH CHILDREN <9 YEARS

(By Hour)

  1. TALLIES OF CHILDREN <9 YEARS INSIDE THE VEHICLES

(By Hour)



    1. Date: _______/_______/2011

    2. Time: ____ ____ : ____ ____

    3. Temperature: ____________

    4. Weather: 1. Clear 2. Cloudy, 3. Fog, 4. Rain 5. Sleet 6. Snow





    1. Date: _______/_______/2011

    2. Time: ____ ____ : ____ ____

    3. Temperature: ____________

    4. Weather: 1. Clear 2. Cloudy, 3. Fog, 4. Rain 5. Sleet 6. Snow





  1. Date: _______/_______/2011

  2. Time: ____ ____ : ____ ___

  3. Temperature: ___________

  4. Weather: 1. Clear 2. Cloudy, 3. Fog, 4. Rain 5. Sleet 6. Snow





  1. NOTES





File Typeapplication/msword
AuthorCharlene.Doyle
Last Modified ByUSDOT User
File Modified2011-03-10
File Created2011-03-10

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