Health Survey of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
support stateB OMB 12_08.doc	Supporting Statement B	Uploaded 2008-12-31	Repair queued
Attachment A rev.doc	Supplementary Document	Uploaded 2008-12-31	Repair queued
Attachment P -IRB letter.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment O.htm	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment N medical records.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment M health survey protocol.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment L consent.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment K tele reminder.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment J reminder email.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment I reminder letter.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment H email reminder.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment G post card reminder.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment F email invite.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment E ltr of invitation.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attachment D prenotice letter.doc	Supplementary Document	Uploaded 2008-12-22	Repair queued
Attach B 60 day FRN.pdf	Supplementary Document	Uploaded 2008-12-22	Repair queued
support stateA OMB 12_08 v2.doc	Supporting Statement A	Uploaded 2008-12-31	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187794	Health Survey Form	Other-Survey	New

ICR Details

OMB Control No:	ICR Reference No: 200901-0923-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/TSDR	Agency Tracking No:
Title: Health Survey of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 10/13/2009
	Date Received in OIRA: 01/14/2009
Terms of Clearance: ATSDR requested to withdraw this ICR; they will resubmit the ICR at a later date.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: On January 28, 2008, President Bush signed H.R. 4986: National Defense Authorization Act for Fiscal Year 2008 requiring ATSDR to develop a health survey of individuals possibly exposed to contaminated drinking water at Camp Lejeune. The Act requires the survey to be developed within 120 days of enactment and to be conducted within one year of enactment. The survey includes questions on cancers and non-fatal diseases that may be associated with solvent exposures. This project proposes to examine the relationship between these diseases and TCE or PCE contaminated water by modeling the exposure to contaminated water while living or working at Camp Lejeune.

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Authorizing Statute(s): PL: Pub.L. 110 - 181 315 Name of Law: National Defense Authorization Act for Fiscal Year 2008
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 40876	07/16/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 810	01/08/2009
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Health Survey Form

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $1,566,667

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? Yes

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)? No

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: 01/14/2009

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