Information Collection

Psychological Constructs Related to Seat Belt Use Survey Screener

IC 227882 under ICR 201708-2127-001 · OMB 2127-0729.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1365 Psychological Constructs Related to Seat Belt Use Survey Screener	Form and Instruction
1365 Survey Screener PCRSBU Form 1365 Screener 021618.docx	Form and Instruction

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 and Instruction	1365	Survey Screener	PCRSBU Form 1365 Screener 021618.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,197

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	10,197	10,197
Annual IC Time Burden (Hours)	170	170
Annual IC Cost Burden (Dollars)	4,385	4,385

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.