ATSDR Technical Assistance (TA) Activity Form

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 5 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 Technical Assistance ﴾TA﴿ Activity Form

This form should be used to capture technical assistance activities provided to internal and external stakeholders. TA activities should not have any conclusions on data or make a health call. ﴾conclusions on data should be captured in LHC, HC or PHA products﴿. For more information on what type of activity is appropriate to capture on this TA form, please see DCHI Document Definitions.

Background Information

TA Activity Name: * Non Site‐specific?

Non site‐specific

(Check box if the TA is NOT for a site)

Is activity related to COVID‐19?

﴾If yes, check box﴿

Street Address ﴾if applicable﴿: City

State *

Please select a value...

Zip Code ﴾if applicable﴿:

Cost Recovery #

Request Information

Date TA activity was requested: * Who requested the assistance?

Please select a value...

Cooperative Agreement Partner?

Coop partner

(If yes, check the box)

Is this activity related to the Choose Safe Places for Early Childcare and Education program?

Choose Safe Places program

(If yes, check the box)

Choose name of TA preparer:

Please summarize the question or assistance requested: *

*Do not include any confidential information such as private citizen names*

Response Information

Date of Response or Activity: *

Check all that apply to this request: Please specify the "other" if that was chosen: Site Visit

Phone Call or Email Public Meeting Presentation Emergency Response Other

Collaborations ﴾who we supported﴿ ﴾check all that apply﴿: Local Health Dept

State Health Dept

State Environmental Agency EPA

CDC

Other

Please summarize the response or assistance that was provided for the request: *

Choose Reviewer for this TA ‐ a link to this TA will be emailed to the reviewer you choose when you click 'Submit' below. *

(State partners should choose TPO. ATSDR staff should choose team lead or branch chief)

Attachments

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