Control Driver Verbal Consent

Prevalence of Alcohol and Other Drug Use among Motor Vehicle Crash Victims Admitted to Select Trauma Centers

Documents and Forms

Document Name Document Type
Form 1421 Control Driver Verbal Consent Form and Instruction
1421 Control Driver Verbal Consent Form 1421 Control Driver Verbal Consent Sept 2018.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Control Driver Verbal Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1421	Control Driver Verbal Consent	Form 1421 Control Driver Verbal Consent Sept 2018.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Air Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.