Information Collection

Drinking Water Exposure Investigation - Dimock, PA

IC 227129 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⚠️ Notice: This information collection may be referencing outdated material.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
Drinking Water Exposure Investigation - Dimock, PA	Form
Dimock Water Exposure Investigation Att4 Qstnnr Dimock EI .docx	Form
Att1 SSA 0923-0048 Dimock EI.docx Supporting Statement A	IC Document
Att2 SSB 0923-0048 Dimock EI .docx Supporting Statement B	IC Document
Att3 Cnsnt Frm Dimock EI .docx Consent	IC Document
Att5 Dimock EI Protocol Final.docx Protocol	IC Document
Att6 EI Smpl Rslts Lttr Dimock EI .docx Sample results letter	IC Document
Att7 Exmpl EI Report .doc Report example	IC Document
Att8 NCEH-ATSDR Research Determination Form Dimock EI -OSSigned.pdf Research determination	IC Document
Att9 Lttr of invittn Fct Sht Dimock EI.docx Invitation and Fact Sheet	IC Document
Dimock EI GenIC Sbmssn Frm.docx GenIC request for approval	IC Document

IC Title:

Drinking Water Exposure Investigation - Dimock, PA

Agency IC Tracking Number:

0923-17AOV

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	none	Dimock Water Exposure Investigation	Att4 Qstnnr Dimock EI .docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances

FR Citation: 59 FR 67085

Number of Respondents: 20

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	20	20
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
Supporting Statement A	Att1 SSA 0923-0048 Dimock EI.docx	06/08/2017
Supporting Statement B	Att2 SSB 0923-0048 Dimock EI .docx	06/08/2017
Consent	Att3 Cnsnt Frm Dimock EI .docx	06/08/2017
Protocol	Att5 Dimock EI Protocol Final.docx	06/08/2017
Sample results letter	Att6 EI Smpl Rslts Lttr Dimock EI .docx	06/08/2017
Report example	Att7 Exmpl EI Report .doc	06/08/2017
Research determination	Att8 NCEH-ATSDR Research Determination Form Dimock EI -OSSigned.pdf	06/08/2017
Invitation and Fact Sheet	Att9 Lttr of invittn Fct Sht Dimock EI.docx	06/08/2017
GenIC request for approval	Dimock EI GenIC Sbmssn Frm.docx	06/08/2017

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