Information Collection

The Regional Center Intake Form

IC 203950 under ICR 201602-2105-004 · OMB 2105-0554.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0554 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DOT F 4500 The Regional Center Intake Form	Form and Instruction
DOT F 4500 The Regional Center Intake Form DOT_F_4500_SBTRC_Field_Office_Intake_Form.doc	Form and Instruction

IC Title:

The Regional Center Intake Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 49 CFR parts 23 and 26 (To search for a specific CFR, visit the Code of Federal Regulations.)

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	DOT F 4500	The Regional Center Intake Form	DOT_F_4500_SBTRC_Field_Office_Intake_Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	-300	400
Annual IC Time Burden (Hours)	600	0	600
Annual IC Cost Burden (Dollars)	0	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.