Information Collection

Exposure Investigation - Blood Lead Levels in Iola, Kansas

IC 224411 under ICR 201512-0923-001 · OMB 0923-0048.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0048 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Exposure Investigation - Blood Lead Levels in Iola, Kansas	Form and Instruction
Iola KS Exposure Investigation Questionnaire Att4 Questionnaire BLL Iola OMB 0923-0048.docx	Form and Instruction
Att3A Parental Permission_BLL in Iola OMB 0923-0048 .docx Parental Permission Form for Venous Blood Sampling for Lead and Questionnaire - Children Less Than 18 Years of Age	IC Document
Att3B Assent Form_BLL Iola OMB 0923-0048 .docx Assent Form for Blood Lead and Questionnaire Youth 6-17 Years of Age	IC Document
Att3C Consent Form_BLL Iola 0923-0048.docx Consent Form for Venous Blood Lead Testing and Questionnaire - Pregnant Women and Women of Childbearing Age	IC Document
Att5_Human Research Determination_Iola EI 0923-0048.pdf Research Determination	IC Document
Att6A letter for child results BBL Iola OMB 0923-0048.docx Sample Results Letter - Younger than 18 Years of Age	IC Document
Att6B letter for women results BLL Iola OMB 0923-0048 .docx Sample Results Letter - Pregnant Woman or Woman of Child Bearing Age	IC Document
Att6C letter inserts BLL IOla OMB 0923-0048.docx Blood Lead Levels - Inserts for Letters	IC Document
Att6D fact sheet inserts BLL Iola OMB 0923-0048.docx Fact Sheets	IC Document
Att7 PFC Serum Sampling_Decatur, AL_HC_EI_04-01-2013_FINAL_26MAR2013.pdf Exposure Investigation Report - Perfluorochemical Serum Sampling Decatur, AL	IC Document
Att2_BLL Iola KS EI SupStatement B - 0923-0048 .docx Supporting Statement B	IC Document
Advance Notification of Urgent Exposure Investigation - Blood Lead Levels in Iola KS Exposure Investigation.msg Advance Notification of Urgent Exposure Investigationo	IC Document
Att1_BLL Iola KS EI SupStatement A - 0923-0048_OMB 11-21-2016 ATSDR final.docx Supportinig Statement A	IC Document
Att8 IOLA KS EI Protocl 08 nov 2016 FINALclean OMB comments 11-21 atsdr final.docx Exposure Investigation Protocol Blood Lead Levels - Iola, KS	IC Document
BBL Iola OMB_GenIC SubmissionForm_0923-0048 edits_OMB 11-21 ATSDR final.docx GenI Submission Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Exposure Investigation - Blood Lead Levels in Iola, Kansas

Agency IC Tracking Number:

17EL

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	NA	Iola KS Exposure Investigation Questionnaire	Att4 Questionnaire BLL Iola OMB 0923-0048.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 or Toxic Substances

FR Citation: 59 FR 67085

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Parental Permission Form for Venous Blood Sampling for Lead and Questionnaire - Children Less Than 18 Years of Age	Att3A Parental Permission_BLL in Iola OMB 0923-0048 .docx	11/14/2016
Assent Form for Blood Lead and Questionnaire Youth 6-17 Years of Age	Att3B Assent Form_BLL Iola OMB 0923-0048 .docx	11/14/2016
Consent Form for Venous Blood Lead Testing and Questionnaire - Pregnant Women and Women of Childbearing Age	Att3C Consent Form_BLL Iola 0923-0048.docx	11/14/2016
Research Determination	Att5_Human Research Determination_Iola EI 0923-0048.pdf	11/14/2016
Sample Results Letter - Younger than 18 Years of Age	Att6A letter for child results BBL Iola OMB 0923-0048.docx	11/14/2016
Sample Results Letter - Pregnant Woman or Woman of Child Bearing Age	Att6B letter for women results BLL Iola OMB 0923-0048 .docx	11/14/2016
Blood Lead Levels - Inserts for Letters	Att6C letter inserts BLL IOla OMB 0923-0048.docx	11/14/2016
Fact Sheets	Att6D fact sheet inserts BLL Iola OMB 0923-0048.docx	11/14/2016
Exposure Investigation Report - Perfluorochemical Serum Sampling Decatur, AL	Att7 PFC Serum Sampling_Decatur, AL_HC_EI_04-01-2013_FINAL_26MAR2013.pdf	11/14/2016
Supporting Statement B	Att2_BLL Iola KS EI SupStatement B - 0923-0048 .docx	11/14/2016
Advance Notification of Urgent Exposure Investigationo	Advance Notification of Urgent Exposure Investigation - Blood Lead Levels in Iola KS Exposure Investigation.msg	11/14/2016
Supportinig Statement A	Att1_BLL Iola KS EI SupStatement A - 0923-0048_OMB 11-21-2016 ATSDR final.docx	11/21/2016
Exposure Investigation Protocol Blood Lead Levels - Iola, KS	Att8 IOLA KS EI Protocl 08 nov 2016 FINALclean OMB comments 11-21 atsdr final.docx	11/21/2016
GenI Submission Form	BBL Iola OMB_GenIC SubmissionForm_0923-0048 edits_OMB 11-21 ATSDR final.docx	11/21/2016

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