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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.