Mild Cognitive Impairment and Driving Performance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NHTSA Form 1240 Mild Cognitive Impairment and Driving Performance	Form	New	Available
Appendix C MoCA-Test-English_2009 - MoCA-Test-English_7_1_KS.pdf	Supplementary Document	Uploaded 2015-09-14	Available
2015.08.14 Fitness_ Appendix B_ justification for instruments_KS_9162015.docx	Supplementary Document	Uploaded 2015-09-17	Available
Appendix A - Authority.docx	Supplementary Document	Uploaded 2014-10-09	Available
30 day notice posting.pdf	Supplementary Document	Uploaded 2014-10-09	Available
60 day notice posting.pdf	Supplementary Document	Uploaded 2014-10-09	Available
2015 07 31 OMB Section B_MCI_FINAL_KS.docx	Supporting Statement B	Uploaded 2015-09-14	Available
2015.08.06 OMB Section A_MCI_FINAL_KS.docx	Supporting Statement A	Uploaded 2015-09-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213454	Mild Cognitive Impairment and Driving Performance	Form	New

ICR Details

OMB Control No: 2127-0712	ICR Reference No: 201410-2127-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOT/NHTSA	Agency Tracking No:
Title: Mild Cognitive Impairment and Driving Performance
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/18/2015
	Date Received in OIRA: 02/27/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved
Responses	90	0	0
Time Burden (Hours)	195	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The National Highway Traffic Safety Administration (NHTSA) of the U.S. Department of Transportation (USDOT) is seeking approval from the Office of Management and Budget (OMB) to conduct a qualifying interview with prospective participants in a study about the consequences of early stage dementia and mild cognitive impairment (MCI) on driving habits, driver performance and safety entitled Mild Cognitive Impairment and Driving Performance. The information from this qualifying interview will be used by NHTSA to determine eligibility for study participation.

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Authorizing Statute(s): US Code: 23 USC 403 Name of Law: Highway Safety Research and Development
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 248	12/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 83	04/30/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Mild Cognitive Impairment and Driving Performance	NHTSA Form 1240, NHTSA Form 1286	Recruitment Form ,   MCI Informed Consent

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	90	0	0	90	0	0
Annual Time Burden (Hours)	195	0	0	195	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The information collection is to determinate eligibility of members of the public for participation in a study assessing the consequences of early stage dementia and mild cognitive impairment (MCI) on driving habits, driver performance, and safety.

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Annual Cost to Federal Government: $1,275

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/27/2015

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