Information Collection

Alcohol and Drug Prevalence

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Alcohol and Drug Prevalence	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	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 %

	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

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.