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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.