Form 1494 Contact Information Form

OMB Control Number: 2127-NEW

Expiration Date: XX/XX/XXXX

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is 2127-NEW (expiration date: MM/DD/YYYY). The average amount of time to complete the survey is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Provide the following so researchers can contact you regarding the study.

Name: ______________________________________

• E-mail: ___________________________________

• Phone: ___________________________________

Best day/time to contact you: _____________________

NHTSA Form 1494