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Eligibility Screening - Adult/Adolescent Field Users
Characterization of Exposure Potential during Activities Conducted on Synthetic Turf with Crumb Rubber Infill
OMB: 0923-0058
IC ID: 226774
OMB.report
HHS/TSDR
OMB 0923-0058
ICR 201708-0923-001
IC 226774
( )
Documents and Forms
Document Name
Document Type
Eligibility Screening - Adult/Adolescent Field Users
Form and Instruction
Field User Eligibility Screening Script
Att4b Field User Eligibility Screening Script_revised 8.24.17_clean.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Eligibility Screening - Adult/Adolescent Field Users
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
NA
Field User Eligibility Screening Script
Att4b Field User Eligibility Screening Script_revised 8.24.17_clean.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
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:
41
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
41
0
0
0
0
41
Annual IC Time Burden (Hours)
3
0
0
0
0
3
Annual IC Cost Burden (Dollars)
25
0
0
0
0
25
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.