Adult and Adolescent Questionnaire

Characterization of Exposure Potential during Activities Conducted on Synthetic Turf with Crumb Rubber Infill

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0058 can be found here:

Documents and Forms

Document Name Document Type
Adult and Adolescent Questionnaire Form
Adult/Adolescent Questionnaire Att4d FieldUser AdultAdolescent Questionnaire_Final.docx Form

Information Collection (IC) Details

IC Title:	Adult and Adolescent 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	none	Adult/Adolescent Questionnaire	Att4d FieldUser AdultAdolescent Questionnaire_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 36	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	36	36
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	131	131

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.