WB-INFO- Individual with Legal Representative

Whistleblower Program Forms

Documents and Forms

Document Name Document Type
Form NHTSA Form 1684 WB-INFO- Individual with Legal Representative Form and Instruction
NHTSA Form 1684 FORM WB-INFO WHISTLEBLOWER SUBMISSION WB-INFO Form (Appendix A to Part 513).docx Form and Instruction
NHTSA Form 1684 FORM WB-INFO WHISTLEBLOWER SUBMISSION WB-INFO Form (Appendix A to Part 513).docx Form and Instruction

Information Collection (IC) Details

IC Title:	WB-INFO- Individual with Legal Representative	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 1684	FORM WB-INFO WHISTLEBLOWER SUBMISSION	WB-INFO Form (Appendix A to Part 513).docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	266,000	266,000

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.