Blood Draw Form

Anniston Community Health Survey: Follow up and Dioxin Analyses (ACHS-II)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0049 can be found here:

Documents and Forms

Document Name Document Type
Att3.12_BloodDrawForm.docx Other-WORD

Information Collection (IC) Details

IC Title:	Blood Draw Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att3.12_BloodDrawForm.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 53 FR 30720

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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