Information Collection

Level 2 ADAS/ADS Incident Reporting

IC 250893 under ICR 202212-2127-004 · OMB 2127-0754.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2127-0754 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHTSA Form 1612 Level 2 ADAS/ADS Incident Reporting	Form and Instruction
NHTSA Form 1612 Level 2 ADAS/ADS Incident Report SGO Incident Report Form and Data Elements_12.29.21.docx	Form and Instruction
NHTSA Form 1612 Level 2 ADAS/ADS Incident Report SGO Incident Report Form and Data Elements_12.29.21.docx	Form and Instruction

IC Title:

Level 2 ADAS/ADS Incident Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	NHTSA Form 1612	Level 2 ADAS/ADS Incident Report	SGO Incident Report Form and Data Elements_12.29.21.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 110

Number of Respondents for Small Entity: 90

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	2,631	2,631
Annual IC Time Burden (Hours)	31,319	31,319
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.