ATSDR Site Impact Assessment Form

Attachment 4c. ATSDR Site Impact Assessment (SIA) Form (Word)

Form Approved OMB Control Number: 0923-0057 Expiration Date: 07/31/2020 ATSDR estimates the average public reporting burden for this collection of information as 7 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).
ATSDR Site Impact Assessment Form Each year, ATSDR reports information on the impact of our program to Congress. This information is also useful for describing the work of our program to other stakeholders and partners. For HQ sites, each site team (health assessor, health educator, regional office, team lead) will fill out a questionnaire for each document released in FY 2014 and later. For state documents, the TPO will work with the state coop staff to fill out the questionnaire. The reviewer selected in the last field will receive a copy of this form to review and approve. Please Contact Matt Sones with any questions.
Site Impact Information
Site Name (Use official name of site):	[system generated from site selected]
Street Address (if there is no specific address, type in “none”):	[system generated from site selected]
City where site is located:	[system generated from site selected]
State where site is located:	[system generated from site selected]
Zip Code:	[system generated from site selected]
Cost Recovery # (enter generic code if no site-specific code is available):	[system generated from site selected]
EPA Facility ID (if known):	[system generated from site selected]
Type of Document (Choose One):	[Drop-down options:] Public Health Assessment Health Consultation Letter Health Consultation Public Comment PHA Public Comment HC
Certified or Non-certified Document:	[Drop-down options:] Certified Non-Certified (state release)
Document Title:	[text field]
Document Release Date:	[date & time field]
Lead Health Assessor:	[text field]
Lead Health Educator (if applicable):	[text field]
Agency Activities and Document Conclusions
Other Information About the Site (check all that apply):	[Check list]: ☐ Conducted exposure investigation/collected data ☐ Provided on-the-ground support during an emergency response ☐ Provided virtual support during an emergency response or acute event ☐ Site is a Brownfields property ☐ Site involves a tribal nation ☐ N/A
Who we worked with at this site (check all that apply):	[Check list]: ☐ Local Health Dept ☐ State Health Dept ☐ State Environmental Agency ☐ EPA ☐ CDC ☐ Community members and organizations ☐ Other ☐ N/A
Number of people assessed:	[number field]
Number of people potentially exposed to contaminants at levels of health concern:	[number field]
Number of people currently exposed to contaminants at levels of health concern:	[number field]
Primary contaminant assessed at the site (Choose only one):	[Drop-down options]: List has over 200 options, including “other”
Other Contaminant(s):	[free text field]
What pathways were evaluated at this site (check all that apply):	[Check list]: ☐ Water ☐ Air ☐ Soil/Sediment ☐ Biota ☐ Physical Hazard
Was enough data available to make a health call?	Yes/No
For ATSDR Use Only:
QC Complete?	[Radio buttons]: Yes No
Choose reviewer for this form (usually Branch Chief or TPO):	[text field]