Alcohol and Drug Prevalence

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 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

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.