Information Collection

Follow Up Biologic Testing for Exposure to Arsenic ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation

IC 226906 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⚠️ Notice: This information collection may be referencing outdated material.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
Follow Up Biologic Testing for Exposure to Arsenic ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation	Form and Instruction
Att 9 Urn Arsnc Lvls in Hayden AZ E Uin Cllctn Instrctns.docx	Instruction
Hayden, Arizona Smelter Exposure Investigation Questiona Att 4 Qstnnr Fllup BlgicTstng Expsre Arsnc Hayden A.pdf	Form and Instruction
Att 3A Prentl Permssn_Fllup BlgicTstng Expsre Arsnc Hayden AZ .docx Parental Permission Form for Children 6 to less than 18 Years of Age	IC Document
Att 3B Assnt Frm_Fllup BlgicTstng Expsre Arsnc Hayden A.docx Assent Form for Children and Youth 7 to less than 18 Years of Age	IC Document
Att 3C Cnst Frm- Fllup BlgicTstng Expsre Arsnc Hayden A.docx Consent Form for Adults Aged 18 years and Over	IC Document
Att 5 RDF Fllup BlgicTstng Expsre Arsnc Hayden AZ.pdf Non-Research Determination	IC Document
Att 6A Rslts lttr Prnt of 6 to 18 - Ttl Arsnc below .docx Sample Results Letter to the Parent of a Participant 6 to	IC Document
Att 6B Rslts Lttr Prtcpnt 6 to 18 – Ttl Abve, Org Not, Inorg Elvtd .docx Sample Results Letter to the Parent of a Participant (6 to	IC Document
Att 6C Rslts Lttr Prtcpnt 6 to 18 - Ttl Abve, Org Elvtd, Inorg Not Elvtd .docx Sample Results Letter to the Parent of a Participant (6 to	IC Document
Att 6D Rslts Lttr Prtcpnt 6 to 18 - Ttl Abv, Org Elvtd, Inorg Elvtd .docx Sample Results Letter to the Parent of a Participant (6 to	IC Document
Att 6E Rslts Lttr Prgnnt Wmn 15 to 45 - Ttl Arsnc Blw .docx Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to	IC Document
Att 6F Rslts Lttr Prgnnt Wmn 15 to 45 years – Ttl Abv, Org Not, Inorg Elvtd .docx Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to	IC Document
Att 6G Rslts Lttr Prgnnt Wmn 15 to 45 years - Ttl Abve Org Elvted Inorg Not Elvtd.docx Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to	IC Document
Att 6H Rslts Lttr Prgnnt Wmn 15 to 45 years - Ttl Abve, Org Elvtd, Inorg Elvtd .docx Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to	IC Document
Att 7 AsarcoHaydenSmelterSite HC EI Report.pdf Health Consultation - Exposure Investigation ASARCO HAYDEN SMELTER SITE	IC Document
Att 8 Urn Arsnc Lvls Hayden AZ Arsnc Rtst Rcruitmnt Lttr.docx Arsenic Retest Recruitment Letter	IC Document
Att 10 Hayden and Winkelman St Map Dmgrphcs.docx Hayden & Winkelman Site Map and Demographics	IC Document
Att 11 Tips for Reducing Exposure to Arsenic.docx Tips for Reducing Exposure to Arsenic	IC Document
Fllup BlgicTstng Expsre Arsnc Hayden AZ EIGenICSbmssnFrm.docx Generic Information Collection (GenIC) Submittal Form for ATSDR Exposure Investigations (EIs) (0923-0048)	IC Document
Att 1 Fllup BlgicTstng Expsre Arsnc Hayden AZ EI SSA.docx Supporting Statement A	IC Document
Att 2 Fllup BlgicTstng Expsre Arsnc Hayden AZ EI SS B.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Follow Up Biologic Testing for Exposure to Arsenic ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation

Agency IC Tracking Number:

0923-0048-17ALA

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	Hayden, Arizona Smelter Exposure Investigation Questionaire	Att 4 Qstnnr Fllup BlgicTstng Expsre Arsnc Hayden A.pdf	NA	Yes	Yes	Fillable Fileable
Instruction			Att 9 Urn Arsnc Lvls in Hayden AZ E Uin Cllctn Instrctns.docx	NA	No		Paper Only

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: 53 FR 30702

Number of Respondents: 60

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	60	60
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Parental Permission Form for Children 6 to less than 18 Years of Age	Att 3A Prentl Permssn_Fllup BlgicTstng Expsre Arsnc Hayden AZ .docx	05/19/2017
Assent Form for Children and Youth 7 to less than 18 Years of Age	Att 3B Assnt Frm_Fllup BlgicTstng Expsre Arsnc Hayden A.docx	05/19/2017
Consent Form for Adults Aged 18 years and Over	Att 3C Cnst Frm- Fllup BlgicTstng Expsre Arsnc Hayden A.docx	05/19/2017
Non-Research Determination	Att 5 RDF Fllup BlgicTstng Expsre Arsnc Hayden AZ.pdf	05/19/2017
Sample Results Letter to the Parent of a Participant 6 to <18 Years of Age â Total Arsenic Below Follow-up Level	Att 6A Rslts lttr Prnt of 6 to 18 - Ttl Arsnc below .docx	05/19/2017
Sample Results Letter to the Parent of a Participant (6 to <18 Years of Age) â Total Arsenic Above Follow-up Level, Organic Arsenic Not Elevated, Inorganic Arsenic Elevated	Att 6B Rslts Lttr Prtcpnt 6 to 18 â Ttl Abve, Org Not, Inorg Elvtd .docx	05/19/2017
Sample Results Letter to the Parent of a Participant (6 to <18 Years of Age) - Total Arsenic Above Follow-up Level, Organic Arsenic Elevated, Inorganic Arsenic Not Elevated	Att 6C Rslts Lttr Prtcpnt 6 to 18 - Ttl Abve, Org Elvtd, Inorg Not Elvtd .docx	05/19/2017
Sample Results Letter to the Parent of a Participant (6 to <18 Years of Age) - Total Arsenic Above Follow-up Level, Organic Arsenic Elevated, Inorganic Arsenic Elevated	Att 6D Rslts Lttr Prtcpnt 6 to 18 - Ttl Abv, Org Elvtd, Inorg Elvtd .docx	05/19/2017
Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to <45 years) - Total Arsenic Below Follow-up Level	Att 6E Rslts Lttr Prgnnt Wmn 15 to 45 - Ttl Arsnc Blw .docx	05/19/2017
Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to <45 years) â Total Arsenic Above Follow-up Level, Organic Arsenic Not Elevated, Inorganic Arsenic Elevated	Att 6F Rslts Lttr Prgnnt Wmn 15 to 45 years â Ttl Abv, Org Not, Inorg Elvtd .docx	05/19/2017
Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to <45 years) - Total Arsenic Above Follow-up Level, Organic Arsenic Elevated, Inorganic Arsenic Not Elevated	Att 6G Rslts Lttr Prgnnt Wmn 15 to 45 years - Ttl Abve Org Elvted Inorg Not Elvtd.docx	05/19/2017
Sample Results Letter to a Pregnant Woman or Woman of Child Bearing Age (15 to <45 years) - Total Arsenic Above Follow-up Level, Organic Arsenic Elevated, Inorganic Arsenic Elevated	Att 6H Rslts Lttr Prgnnt Wmn 15 to 45 years - Ttl Abve, Org Elvtd, Inorg Elvtd .docx	05/19/2017
Health Consultation - Exposure Investigation ASARCO HAYDEN SMELTER SITE	Att 7 AsarcoHaydenSmelterSite HC EI Report.pdf	05/19/2017
Arsenic Retest Recruitment Letter	Att 8 Urn Arsnc Lvls Hayden AZ Arsnc Rtst Rcruitmnt Lttr.docx	05/19/2017
Hayden & Winkelman Site Map and Demographics	Att 10 Hayden and Winkelman St Map Dmgrphcs.docx	05/19/2017
Tips for Reducing Exposure to Arsenic	Att 11 Tips for Reducing Exposure to Arsenic.docx	05/19/2017
Generic Information Collection (GenIC) Submittal Form for ATSDR Exposure Investigations (EIs) (0923-0048)	Fllup BlgicTstng Expsre Arsnc Hayden AZ EIGenICSbmssnFrm.docx	05/19/2017
Supporting Statement A	Att 1 Fllup BlgicTstng Expsre Arsnc Hayden AZ EI SSA.docx	05/19/2017
Supporting Statement B	Att 2 Fllup BlgicTstng Expsre Arsnc Hayden AZ EI SS B.docx	05/19/2017

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