1457 Teen Data Collection Prior to Training

OMB Control Number: 2127-NEW

Expiration Date: MM/DD/YYYY

Teen Data Collection Prior to Training (Computer Screen)

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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-NEW (expiration date: MM/DD/YYYY). Public reporting for this collection of information is estimated to be approximately 3 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. 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.

[Program generates the date these data are collected.]

Please answer all of the questions below:

What is your name: ________ (First) ________________(Last)

What is your home mailing address: ____________________

What is your email address: __________________________

Please re-enter: __________________________

What is your home telephone number: __________________

What is your cell phone number: ___________________

What is your date of birth: __ (Day) __ (Month) ____ (Year)

What is your Driver’s License Number: _______________

Please re-enter: _______________

What is your gender: ____ (Male) ____ (Female)

What is your race (select one or more):

____ (American Indian or Alaska Native)

____ (Asian)

____ (Black or African American)

____ (Native Hawaiian or Other Pacific Islander)

____ (White)

What is your ethnicity (select one):

____ (Hispanic or Latino)

____ (Not Hispanic or Latino)

Have you completed a driver education/training course? __ (Yes) __ (No)

If yes, please describe by checking one or more of the following options:

• Hazard perception training

• Skid control/emergency maneuvers course

• First aid training

• Other:______________________________

NHTSA Form 1457