Information Collection

Site-Specific Evaluation (post-intervention evaluation only)

IC 181194 under ICR 200707-0923-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Site-Specific Evaluation (post-intervention evaluation only)	Form and Instruction
Additional Optional Survey Modules on Demographics, QOL, Attachment G Additional Modules.doc	Form and Instruction
CEEPM Module - Contaminant Group, Env Media, and Env Pat Attachment F3. PROPOSED CEEPM Reference Modules.doc	Form and Instruction
Attachment L2 Sample Cover Letter for Post.doc Sample Letter for Post-Intervention Evaluation	IC Document
Attachment M Sample Interviewer Scripts.doc Sample Interviewer Scripts	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Additional Optional Survey Modules on Demographics, QOL, Stress, Intention to Change, Knowledge and Beliefs	Attachment G Additional Modules.doc		No	No	Paper Only
Form and Instruction	None	CEEPM Module - Contaminant Group, Env Media, and Env Pathway	Attachment F3. PROPOSED CEEPM Reference Modules.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 59 FR 67085

Number of Respondents: 10,750

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,750	10,750
Annual IC Time Burden (Hours)	3,583	3,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Letter for Post-Intervention Evaluation	Attachment L2 Sample Cover Letter for Post.doc	06/22/2007
Sample Interviewer Scripts	Attachment M Sample Interviewer Scripts.doc	06/22/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.