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Eligibility Screening
[ATSDR] Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study
OMB: 0923-0063
IC ID: 239035
OMB.report
HHS/TSDR
OMB 0923-0063
ICR 202305-0923-001
IC 239035
( )
Documents and Forms
Document Name
Document Type
Eligibility Screening
Form and Instruction
Eligibility screener
M_Att04 ElgbltyScrng_20201027_updt.docx
Form and Instruction
Eligibility screener
M_Att04 ElgbltyScrng_20201027_updt.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Eligibility Screening
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
none
Eligibility screener
M_Att04 ElgbltyScrng_20201027_updt.docx
Yes
Yes
Fillable Fileable
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:
7,982
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
7,982
0
0
0
0
7,982
Annual IC Time Burden (Hours)
1,330
0
0
0
0
1,330
Annual IC Cost Burden (Dollars)
33,231
0
0
0
0
33,231
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.