Impact Analysis - Consent Form

Form Approval OMB No. 2137-0034

Hazardous Materials Shipping Papers and Emergency Response Information

Informed Consent Form for Impact Analysis

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information unless it displays a current valid OMB control number. The valid OMB control number for this information collection is 2137-0034. The information requested on this form is being collected by the U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration (PHMSA). Public reporting burden for this collection of information is estimated to be 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. All responses to this collection are voluntary. Send comments regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Mr. T. Glenn Foster, Information Collection Clearance Officer, U. S. Department of Transportation, PHMSA, Office of Hazardous Materials Safety, PHH-10, 1200 New Jersey Ave., S.E., 2^nd Floor East, E24-301, Washington, DC 20520.

Name of Agency/Company/Organization (print): _____________________________________________________________

Background for Pilot Tests and Volunteer Participants

• The Pipeline and Hazardous Materials Safety Administration (PHMSA) must evaluate the feasibility and effectiveness of paperless hazard communications systems by conducting pilot tests and make a recommendation to Congress regarding whether a regulatory change allowing for the use of electronic hazard communication systems is warranted.

• The data collected during the pilot tests and associated information collection efforts are intended to ensure that the evaluation and feasibility report required under the Moving Ahead for Progress in the 21^st Century (MAP-21) Act focuses on the results and includes data supporting the recommendation for possible implementation of electronic hazard communication systems into the Federal hazardous material transportation safety program.

• Current shipping paper requirements as written in 49 CFR, Part 172 will still need to be met during the pilot test. Hardcopy shipping papers will still be required to be carried on all transportation conveyances included in the pilot tests.

• PHMSA will conduct pilot tests in three or four regions of the US: Northeast, Southwest, Southeast, and Northwest; at least one of the pilot test regions will include a rural area.

• Participation in the pilot tests is completely voluntary. Participants will not receive any financial compensation and are expected to use their own equipment and staff resources.

Confidentiality and Privacy Protection

PHMSA published a 60-Day Notice and requested comments in the Federal Register (PHMSA-2013-0124; Notice No. 13-7) pertaining to information collection associated with the Paperless Hazard Communications Pilot Program, authorized by Section 33005 of MAP–21. The collection and use of the data provided by volunteer participants are consistent with the provisions of 5 U.S.C. 552a (Privacy Act of 1974). Any information obtained during the pilot tests will be used strictly for evaluation purposes. No Personally Identifiable Information (PII) will be disseminated or disclosed in any way without prior written consent from the source individual and company/organization.

I understand that this form covers my agency’s/company’s/organization’s voluntary completion of the Impact Analysis Question Set developed by PHMSA to collect initial nonprobability data from a subset of the hazardous materials stakeholder community, and that this data will be used by PHMSA to identify non-generalizable information regarding the benefits and limitations associated with the use of electronic communications with respect to HM shipping paper data.

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask PHMSA questions about it and any questions that I have asked have been answered to my satisfaction. I voluntarily consent to participate as a volunteer in this pilot program information collection effort. I understand that information I provide will be kept private to the extent provided by law.

Name of Participant (print): _______________________________________ Date: __________________________

Title: __________________________________________________________________________________________________

Signature of Participant: _________________________________________________________________________________

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