Information Collection

Mild Cognitive Impairment and Driving Performance

IC 213454 under ICR 201410-2127-001 · OMB 2127-0712.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHTSA Form 1240 Mild Cognitive Impairment and Driving Performance	Form
NHTSA Form 1240 Recruitment Form NHTSA Form 1240 Screening quest_KS.docx	Form
NHTSA Form 1286 MCI Informed Consent NHTSA Form 1286 MCI Informed Consent_KS.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NHTSA Form 1240	Recruitment Form	NHTSA Form 1240 Screening quest_KS.docx		Yes	No	Fillable Fileable
Form	NHTSA Form 1286	MCI Informed Consent	NHTSA Form 1286 MCI Informed Consent_KS.docx		No		Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	195	195
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.