Information Collection

Wellness Questionnaire

IC 268183 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form NHTSA Form 1747 Wellness Questionnaire	Form
NHTSA Form 1747 Wellness Questionnaire Form1747_WellnessQuestionnaire.docx	Form
NHTSA Form 1747 Wellness Questionnaire Form1747_WellnessQuestionnaire.docx	Form

IC Title:

Wellness Questionnaire

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	NHTSA Form 1747	Wellness Questionnaire	Form1747_WellnessQuestionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	300	300
Annual IC Time Burden (Hours)	25	25
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.