Form NHTSA Form 1278 NHTSA Form 1278 Interview Form Cover Sheet

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

Interview Form Cover Sheet
PSU Number
Case Number

___ ___

Interviewee(s) Role or Name(s):
_____________________________________________

___ ___ ___ ___

_____________________________________________

Vehicle Number ___ ___

Phone Number: (
Occupant
#

Name

Date of
Birth

)

Medical Facility
(If multiple treatment locations – list all)

Discharge
Date(s)

1
2
3
4
5
6
Date, Time and Place
to have medical release signed:

Other identifying information:

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.
The OMB Control Number for this information collection is 2127-0706. Public reporting for this collection of
information is estimated to be approximately 30 minutes per response, including the time for reviewing
instructions, completing and reviewing the collection of information. All responses to this collection of
information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to: Information Collection Clearance Officer,
National Highway Traffic Safety Administration, 1200 New Jersey Ave, SE, Washington, DC 20590.
NHTSA Form 1278 (12/2017)

Interview Form Cover Sheet – January 2018 edition