OMB
.report
Search
Adult Consent
Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)
OMB: 0923-0059
IC ID: 233851
OMB.report
HHS/TSDR
OMB 0923-0059
ICR 202206-0923-001
IC 233851
( )
Documents and Forms
Document Name
Document Type
Adult Consent
Form
Adult consent
PrtApndxB2_AdultConsentForm_20220609.docx
Form
Adult consent
PrtApndxB2_AdultConsentForm_20220609.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Adult Consent
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
none
Adult consent
PrtApndxB2_AdultConsentForm_20220609.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances
FR Citation:
76 FR 4432
Number of Respondents:
864
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
864
0
-637
0
0
1,501
Annual IC Time Burden (Hours)
144
0
-106
0
0
250
Annual IC Cost Burden (Dollars)
4,033
0
-2,046
0
0
6,079
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.