Information Collection

Alcohol and Drug Prevalence

IC 236916 under ICR 201907-2127-001 · OMB 2127-0744.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1421 Alcohol and Drug Prevalence	Form
1421 De-identified Data Provided by Trauma Center or Medical Data Collection Items July 17 2019.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	1421	De-identified Data Provided by Trauma Center or Medical Examiner	Data Collection Items July 17 2019.docx		Yes	No	Fillable Printable

Line of Business: Transportation

Subfunction: Air Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,500

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	7,500	7,500
Annual IC Time Burden (Hours)	0	0
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.