Screener Form

Fatal Crash Seat Belt Use Reporting and Awareness

Documents and Forms

Document Name Document Type
Form 1604 Screener Form Form and Instruction
1604 Screener Form Form 1604_Screener Form_Fatal Crash project 012522 (1).docx Form and Instruction
1604 Screener Form Form 1604_Screener Form_Fatal Crash project 012522 (1).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Screener Form	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 and Instruction	1604	Screener Form	Form 1604_Screener Form_Fatal Crash project 012522 (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,170	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,170	4,170
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	2,094	2,094

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.