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View Information Collection (IC)

Supplemental Exposure Investigation at Select PFAS Exposure Assessment Sites 0923-0048-21GQ
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0923-0048 Household Recruitment Script Att7_ApxA2_Recruitment Scripts.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Household Questionnaire - Adult (Dust Only) Att14_ApxC1_Household Quest _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Personal Exposure Questionnaire - Adult (Dust Only) Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Environmental Sampling Collection Form - Adult (Dust Only) Att18_ApxD1_PFAS Sampling Coll Form _Dust.docx NA No   Paper Only
Form and Instruction 0923-0048 Household Questionnaire - Adult (Robust) Att14_ApxC1_Household Quest _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Personal Exposure Questionnaire - Adult (Robust) Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Environmental Sampling Collection Form - Adult (Robust) Att19_ApxD2_PFAS Sampling Coll Form_Robust _ FINAL.docx NA No   Paper Only
Form and Instruction 0923-0048 Personal Exposure Questionnaire - Adult Consent (Self Only) Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Personal Exposure Questionnaire - Child (12-17 Years) Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx NA Yes Yes Fillable Fileable
Form and Instruction 0923-0048 Personal Exposure Questionnaire - Child (Less than 12) Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx NA Yes Yes Fillable Fileable

Health Public Health Monitoring

09-19-0001 - Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances  76 FR 4431

600 0
   
Individuals or Households
 
   55 %

  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 600 0 600 0 0 0
Annual IC Time Burden (Hours) 351 0 351 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
0923-0048 GenIC Submission Form 0 - GenIC SubmssnFrm_SupplmntlPFAS_EI.docx 02/17/2022
Supporting Statement A Att1_PFAS Environ Sampling EI SSA - 0923-0048_FINAL.docx 02/17/2022
Supporting Statement B Att2_PFAS Environ Sampling EI SSB - 0923-0048 FINAL .docx 02/17/2022
Environmental Sampling Protocol Att5_PFAS Environ Sampling EI Protocol _ FINAL .docx 02/17/2022
Household Recruitment Letter Att6_Apx A1_Household Recruitment Letter .docx 02/17/2022
Appointment Verification Letter Att8_ApxA3_Appt Verification Letter.docx 02/17/2022
Adult Consent 1 Att10_ApxB2_Adult Consent1.docx 02/17/2022
Adult Consent 2 Att11_ApxB3_Adult Consent2.docx 02/17/2022
Parental Permission Att12_ApxB4_Parental Permission.docx 02/17/2022
Assent Form Att13_ApxB5_Assent Form.docx 02/17/2022
Sampling and Analysis Plan (SAP) Att17_ApxD_SAP_FINAL.docx 02/17/2022
Health and Safety Plan Att20_ApxE_H&S Plan.docx 02/17/2022
Results Letter - Dust Only Att21_ApxF1_Results Letter_dust only.docx 02/17/2022
Results Letter - Robust Att22_ApxF2_Results Letter_Robust.docx 02/17/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.