Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

OMB 0923-0059

This information collection addresses the requirements for completing exposure assessments (EAs) for PFAS authorized in Section 8006 of the Consolidated Appropriations Act, 2018. ATSDR/NCEH will use statistical methods to recruit respondents at a minimum of eight current or former domestic military installations known to have PFAS contamination in water sources. ATSDR will collect biological and environmental samples to evaluate exposure. This request for non-material change will enable virtual meetings and telephone interviews instead of in-person contact. The changes are being made due to COVID-19 precautions and the need to practice social distancing.

The latest form for Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs) expires 2022-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
EA Participants (All Ages) - Biological Testing Tracking Form
Environmental Sample Collection Form Form
Environmental Sampling Consent Form
Household Recruitment Script for Environmental Sampling Form and Instruction
Exposure Questionnaire for Biological Testing - Child Completed Form
Child Assent Form and Instruction
Exposure Questionnaire for Biological Testing - Parent Proxy Form
Parental Permission Form
Adult Exposure Assessment Questionnaire Form
Adult Consent Form
Household Eligibility Screener Form and Instruction
Community Event Evaluation Survey Form
PrtApndxK_Crosswalk table for Protocol Modifications.xlsx Supplementary Document
PrtApndxJ_PFAS EA Restart Plan_v8.docx Supplementary Document
PrtApndxC1_SampleCollectionLog_20191108.docx Supplementary Document
PrtApndxB1_PrivacyActStatement_20191108.docx Supplementary Document
PrtApndxA2_HHRecruitmentLetter_20220609.docx Supplementary Document
PFAS Exposure Assessment Protocol Revision clean.docx Supplementary Document
PrtApndxE_UrineCollctnInstrctns_20191108.docx Supplementary Document
PrtApndxD_ChainCustodyForms_20191108.docx Supplementary Document
PrtApndxI_Data MangmntPlan_revision clean.docx Supplementary Document
PrtApndxH_SiteHlthSafety Plan_06_02_2020.docx Supplementary Document
1 - PFAS EA SSB_2022_6_1_22.docx Supporting Statement B
1 - PFAS EA SSA_2022_6_1_22.docx Supporting Statement A
PrtApndxG2_RsultsLttrEnviroSmpling 20200109.docx Supplementary Document
PrtApndxG1_RsultsLttrBiolgcSmplng 20200109.docx Supplementary Document
Att6 STARS Determination.pdf Supplementary Document
Att5 PIA_PFAS EA signed OCISO 20220509.pdf Supplementary Document
Att4 PFAS EA Example report-508.pdf Supplementary Document
Att3 PFAS EA Technical Tools (PEATT).pdf Supplementary Document
Att2 0923-0059 PFAS EA 60D FRN.pdf Supplementary Document
Att1 AuthLegsl PFAS EA.docx Supplementary Document
EA Participants (All Ages) - Biological Testing Tracking Form
Environmental Sample Collection Form Form
Environmental Sampling Consent Form
Household Recruitment Script for Environmental Sampling Form and Instruction
Exposure Questionnaire for Biological Testing - Child Completed Form
Child Assent Form and Instruction
Exposure Questionnaire for Biological Testing - Parent Proxy Form
Parental Permission Form
Adult Exposure Assessment Questionnaire Form
Adult Consent Form
Household Eligibility Screener Form and Instruction
Community Event Evaluation Survey Form

All Historical Document Collections

202206-0923-001 Approved without change	Revision of a currently approved collection	2022-06-17
202006-0923-001 Approved with change	No material or nonsubstantive change to a currently approved collection	2020-06-18
202002-0923-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-14
202001-0923-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-01-31
202001-0923-003 Improperly submitted and continue	No material or nonsubstantive change to a currently approved collection	2020-01-10
201907-0923-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-07-29
201811-0923-001 Approved with change	New collection (Request for a new OMB Control Number)	2018-11-29

OMB Details

Community Event Evaluation Survey

Federal Enterprise Architecture: Health - Public Health Monitoring

Form none

Exposure assessment community event survey

Paper Only

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.