Information Collection

Screening Questionnaire

IC 256598 under ICR 202210-2127-005 · OMB 2127-0763.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1627 Screening Questionnaire	Form and Instruction
1627 Screening Questionnaire ADAS ICR Form 1627 Screening 111921-asg RAA.docx	Form and Instruction
1627 Screening Questionnaire ADAS ICR Form 1627 Screening 111921-asg RAA.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	1627	Screening Questionnaire	ADAS ICR Form 1627 Screening 111921-asg RAA.docx		Yes	No	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	7,230	7,230

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.