Information Collection

Health Screening Only

IC 252023 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⚠️ Notice: This information collection may be referencing outdated material.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 NHTSA Form 1649 Health Screening Only	Form
NHTSA Form 1649 Health Screener PRA_DADSS_FOT_Health Screen.docx	Form
NHTSA Form 1649 Health Screener PRA_DADSS_FOT_Health Screen.docx	Form

IC Title:

Health Screening Only

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	NHTSA Form 1649	Health Screener	PRA_DADSS_FOT_Health Screen.docx		No		Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 117

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	249	249
Annual IC Time Burden (Hours)	117	117
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.