Information Collection

Highway Safety Questionnaire

IC 239138 under ICR 202001-2127-001 · OMB 2127-0747.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1495 Highway Safety Questionnaire	Form and Instruction
1495 Highway Safety Questionnaire 1495 Highway Safety Questionnaire 20190924.docx	Form and Instruction

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 and Instruction	1495	Highway Safety Questionnaire	1495 Highway Safety Questionnaire 20190924.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	600	600
Annual IC Time Burden (Hours)	250	250
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.