Surveillance and Epidemiology Study Core Questionnaire and Supplemental Modules

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
111133	Surveillance and Epidemiology Study Core Questionnaire and Supplemental Modules	Migrated

ICR Details

OMB Control No: 0923-0010	ICR Reference No: 199507-0923-001
Status: Historical Inactive	Previous ICR Reference No: 199209-0923-001
Agency/Subagency: HHS/TSDR	Agency Tracking No:
Title: Surveillance and Epidemiology Study Core Questionnaire and Supplemental Modules
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved and continue	Conclusion Date: 09/29/1995
	Date Received in OIRA: 07/05/1995
Terms of Clearance: The revisions to the Surveillance and Epidemiology ICR are dis- approved while the original ICR's Core Questionnaire and Sup- plemental Modules approval (dated 11/25/92) is approved by six months. ASTDR should follow the new requirements under the Pap- erwork Reduction Act for public comment prior to revision focus- ing on the modified questionnaires and the practical utility of collecting the different information and how it will be used. OMB is prepared to work with ASTDR to review the modifications prior to resubmittal to develop better instruments that meet the re- quirements of the PRA.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/1995	05/31/1996	10/31/1995
Responses	6,000	0	0
Time Burden (Hours)	4,938	0	4,938
Cost Burden (Dollars)	0	0	0

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Abstract: ATSDR is revising and renewing this project which follows populations exposed to specified hazardous substances over a period of time to determine if they are experiencing elevated occurrence of diseases. In addition to demographic information, additional core information is collected concerning behavioral characteristics and health conditions. The same supplemental modules are also included in the request that may be used, depending on the organ system targeted or the type of respondent (renal, liver, occupational, respiratory, and neurotoxic). New modules added are: children's, acute, skin, ...

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Surveillance and Epidemiology Study Core Questionnaire and Supplemental Modules

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/05/1995

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