Information Collection

Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)

IC 226479 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0222 Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	Form and Instruction
0920-0222 Imp Driving - Attach 3 Screener rev-kw Imp Driving - Attach 3 Screener rev-kw.docx	Form and Instruction
0920-0222 Imp Driving - Attach 5 Resp Data Collection Sheet Imp Driving - Attach 5 Resp Data Collection Sheet.docx	Form and Instruction
Impaired Driving 10-day ltr 041417.docx Impaired Driving 10-day ltr 041417	IC Document
Imp Driving - Attach 1 Qnne rev.docx Imp Driving - Attach 1 Qnne rev	IC Document
Imp Driving - Attach 2a-c Ad&Flyers.docx Imp Driving - Attach 2a-c Ad&Flyers	IC Document
Imp Driving - Attach 4 Informed Consent.docx Imp Driving - Attach 4 Informed Consent	IC Document
Imp Driving - Attach 6 Thank You letter.docx Imp Driving - Attach 6 Thank You letter	IC Document
Imp Driving - Attach 7 Adult Special Consent.docx Imp Driving - Attach 7 Adult Special Consent	IC Document

IC Title:

Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)

Agency IC Tracking Number:

17AEY

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 and Instruction	0920-0222	Imp Driving - Attach 3 Screener rev-kw	Imp Driving - Attach 3 Screener rev-kw.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-0222	Imp Driving - Attach 5 Resp Data Collection Sheet	Imp Driving - Attach 5 Resp Data Collection Sheet.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 112

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Impaired Driving 10-day ltr 041417	Impaired Driving 10-day ltr 041417.docx	04/20/2017
Imp Driving - Attach 1 Qnne rev	Imp Driving - Attach 1 Qnne rev.docx	04/20/2017
Imp Driving - Attach 2a-c Ad&Flyers	Imp Driving - Attach 2a-c Ad&Flyers.docx	04/20/2017
Imp Driving - Attach 4 Informed Consent	Imp Driving - Attach 4 Informed Consent.docx	04/20/2017
Imp Driving - Attach 6 Thank You letter	Imp Driving - Attach 6 Thank You letter.docx	04/20/2017
Imp Driving - Attach 7 Adult Special Consent	Imp Driving - Attach 7 Adult Special Consent.docx	04/20/2017

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