Information Collection

Appendix I - Cognitive Pre-Screener

IC 236368 under ICR 201905-2127-007 · OMB 2127-0745.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHTSA 1391 Appendix I - Cognitive Pre-Screener	Form
NHTSA 1391 Appendix I - Cognitive Pre-Screener Appendix I - Cognitive Pre-Screener -5-21-19 (003).docx	Form

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	NHTSA 1391	Appendix I - Cognitive Pre-Screener	Appendix I - Cognitive Pre-Screener -5-21-19 (003).docx		No		Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	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.