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ATTACHMENT III |
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Survey Form sent to State Reporting Agencies |
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| Survey for 2010 Firearm Inquiry Statistics (FIST) Program |
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OMB No. XXXX-XXXX: Approval expires XX/XX/XXXX |
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| State Agency Name: |
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Agency Number: |
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APPLICATIONS |
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REASONS FOR REJECTION |
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APPEALS/ARRESTS** |
| Month |
RCVD |
REJ |
REJ RATE |
FEL |
FUG |
JUV |
DOM VIOL |
CRT ORD |
ILLGL ALIEN |
MNTL HLTH |
DRUG ADD |
STATE LAW |
OTHER* |
ARRESTS |
APPEALS |
APPEALS REVRSD |
RECONSD RCVD† |
RECONSD REVRSD |
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| Feb |
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| Mar |
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| April |
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| May |
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| June |
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| July |
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| Aug |
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| Sep |
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| Oct |
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| Nov |
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| Dec |
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| TOTAL |
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| *Other includes dishonorable discharge, renunciation of U.S. citizenship, and unspecified reasons. |
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| **Arrest and appeal counts can be sent later, if more time is needed to collect data. |
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| † A reconsideration occurs when the denied person objects to the original decision and asks your agency to reconsider the denial. |
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| Directions: If monthly totals are not available, please fill in the cumulative totals for at least the first two columns. In the event data are reported on the |
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| spreadsheet, please review the accuracy of the information and make updates directly to the form as needed. In order for us to complete our analyses of |
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| the 2010 data, we would greatly appreciate if you would return the completed spreadsheet and your signed review by <date>. The materials can be returned |
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| via fax, mail, or email (information below). |
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| Thank you for your time and effort. Please do not hesitate to contact us at 1-800-XXX-XXXX or [email protected] with any questions regarding this survey. |
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| Completed by: |
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MAIL: |
FIST |
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| Telephone: |
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<Data collection agent> |
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| Fax: |
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<Address> |
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| Email: |
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<City, State, Zip Code> |
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