Information Collection

NCEH/ATSDR Exposure Investigations (EI)

IC 43625 under ICR 201208-0923-001 · OMB 0923-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no form number NCEH/ATSDR Exposure Investigations (EI)	Form and Instruction
no form number Chemical Exposure Questions Attachment 3_Revised _Chemical Exposure Questions.doc	Form and Instruction
Attachment 6. Example Human Subjects Research Determination Form.pdf Attachment 6	IC Document
Attachment 4. Combined set other agencies.doc Attachment 4	IC Document
Attachment 5. Example Consent Form.doc Attachment 5	IC Document

IC Title:

NCEH/ATSDR Exposure Investigations (EI)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	no form number	Chemical Exposure Questions	Attachment 3_Revised _Chemical Exposure Questions.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-19-001 Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (ATSDR)

FR Citation: 57 FR 62814

Number of Respondents: 700

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	Previously Approved
Annual Number of Responses for this IC	700	-50	750
Annual IC Time Burden (Hours)	350	-25	375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 6	Attachment 6. Example Human Subjects Research Determination Form.pdf	07/31/2012
Attachment 4	Attachment 4. Combined set other agencies.doc	07/31/2012
Attachment 5	Attachment 5. Example Consent Form.doc	07/31/2012

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