NHTSA Form 1063 Vehicle Inspection Form

ATTACHMENT D4

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 2127-0626. Since data will be collected on this form via observation and inspection, 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 1063

U.S. Department of Transportation National Highway Traffic Safety Administration

VEHICLE INSPECTION FORM (5/27/10 Draft)

Form Approved O.M.B. No. 2127-0626 Expiration Date: XXXX National Automotive Sampling System Tire Pressure Monitoring System-Special Study

Primary Sampling Unit Number Site Number	Observation Number Date of Observation ___ ___ / ___ ___ / 2010
VEHICLE IDENTIFICATION

Vehicle Model Year Vehicle Make Vehicle Model Vehicle Mileage ___________________	Vehicle Body Type Category Automobiles: Small Large Utility Vehicles Van Based Light Trucks Light Conventional Trucks
Vehicle Identification Number (VIN) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Left justify; Slash zeros and letter Z ( and ) --No VIN—Code all zeros --Unknown—Code all nines

TPMS INFORMATION

11. TPMS Display

    1. Display Only No, Yes

    2. Tire Specific Warning Icon: No, Yes

    3. Tire Specific PSI: No, Yes

LF Tire ___ ___psi LR Tire ___ ___psi

RR Tire ___ ___psi RF Tire ___ ___psi

PLACARD/OWNER’S MANUAL INFORMATION

12. GVWR ____ ____ ____ ____ lbs

13. Manufacturer’s Recommended Tire Size* __________________

14. Manufacturer Recommended Cold Tire Pressure (Front)** ____ ____ psi

15. Manufacturer Recommended Cold Tire Pressure (Rear)** ____ ____ psi

16. Manufacturer Recommended Hot Tire Pressure (Front)** ____ ____ psi

17. Manufacturer Recommended Hot Tire Pressure (Rear)** ____ ____ psi

* If more than one tire size is recommended, refer to the procedures document.

** If placard/manual does not specify hot or cold and shows only one pressure amount, code the specified amount in “Cold” and code N/A in “Hot. OR refer to procedures manual