Information Collection

Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands

IC 215956 under ICR 201409-0923-001 · OMB 0923-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0051 can be found here:

Documents and Forms

Document Name Document Type
Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands Form and Instruction
ACE Adult/Child/Pet Survey Attachment B_General Survey_Methyl Bromide.docx Form and Instruction
Attachment A_EpiAid_request_MethylBrom.pdf U.S. Virgin Islands Request for Assistance IC Document
Attachment C_MedChartAbstrct Form.docx Medical Chart Abstraction Form (if required) IC Document
Attachment D_ACE Survey Consent Form_Methyl Bromide.docx ACE Survey Consent Form IC Document
Request ACE Investigation Form_Methyl Bromide Signed.pdf Request for ACE Investigation IC Document
Supporting Statement B_Methyl Bromide.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands	Agency IC Tracking Number:	15ZL

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
Form and Instruction	None	ACE Adult/Child/Pet Survey	Attachment B_General Survey_Methyl Bromide.docx	None	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 Hazardous	FR Citation: 53 FR 30702

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
U.S. Virgin Islands Request for Assistance	Attachment A_EpiAid_request_MethylBrom.pdf	04/03/2015
Medical Chart Abstraction Form (if required)	Attachment C_MedChartAbstrct Form.docx	04/03/2015
ACE Survey Consent Form	Attachment D_ACE Survey Consent Form_Methyl Bromide.docx	04/03/2015
Request for ACE Investigation	Request ACE Investigation Form_Methyl Bromide Signed.pdf	04/03/2015
Supporting Statement B	Supporting Statement B_Methyl Bromide.docx	04/03/2015

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