Information Collection

Eligibility/Demographic Interview

IC 252021 under ICR 202203-2127-002 · OMB 2127-0734.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2127-0734 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHTAS Form 1647 Eligibility/Demographic Interview	Form
NHTAS Form 1647 Eligibility Demographic Questionnaire PRA_DADSS_FOT_Eligibility Demographic Questionnaire.docx	Form
NHTAS Form 1647 Eligibility Demographic Questionnaire PRA_DADSS_FOT_Eligibility Demographic Questionnaire.docx	Form

IC Title:

Eligibility/Demographic Interview

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	NHTAS Form 1647	Eligibility Demographic Questionnaire	PRA_DADSS_FOT_Eligibility Demographic Questionnaire.docx		No		Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,393

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,393	1,393
Annual IC Time Burden (Hours)	697	697
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.