Information Collection

Eligibility Questionnaire

IC 268178 under ICR 202405-2127-003 · OMB 2127-0771.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2127-0771 can be found here:

Documents and Forms

Document Name Document Type
Form NHTSA Form 1742 Eligibility Questionnaire Form and Instruction
NHTSA Form 1742 Eligibility Questionnaire Form1742_EligibilityQuestionnaire.docx Form and Instruction
NHTSA Form 1742 Eligibility Questionnaire Form1742_EligibilityQuestionnaire.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Questionnaire	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 and Instruction	NHTSA Form 1742	Eligibility Questionnaire	Form1742_EligibilityQuestionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 233	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	233	233
Annual IC Time Burden (Hours)	43	43
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.