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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.