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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)
Agency IC Tracking Number:
17AEY
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
0920-0222
Imp Driving - Attach 3 Screener rev-kw
Imp Driving - Attach 3 Screener rev-kw.docx
Yes
Yes
Fillable Printable
Form and Instruction
0920-0222
Imp Driving - Attach 5 Resp Data Collection Sheet
Imp Driving - Attach 5 Resp Data Collection Sheet.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population 09-20-0164
FR Citation:
49 FR 37693
Number of Respondents:
112
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
112
0
112
0
0
0
Annual IC Time Burden (Hours)
46
0
46
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Impaired Driving 10-day ltr 041417
Impaired Driving 10-day ltr 041417.docx
04/20/2017
Imp Driving - Attach 1 Qnne rev
Imp Driving - Attach 1 Qnne rev.docx
04/20/2017
Imp Driving - Attach 2a-c Ad&Flyers
Imp Driving - Attach 2a-c Ad&Flyers.docx
04/20/2017
Imp Driving - Attach 4 Informed Consent
Imp Driving - Attach 4 Informed Consent.docx
04/20/2017
Imp Driving - Attach 6 Thank You letter
Imp Driving - Attach 6 Thank You letter.docx
04/20/2017
Imp Driving - Attach 7 Adult Special Consent
Imp Driving - Attach 7 Adult Special Consent.docx
04/20/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.