Information Collection

Blood Lead and Urine Arsenic Levels in Anaconda, MT - Exposure Investigation

IC 232880 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0923-0048 Blood Lead and Urine Arsenic Levels in Anaconda, MT - Exposure Investigation	Form and Instruction
0923-0048 Anaconda MT Exposure Investigation Questionnaire Att4_Questionnaire_AnacondaEI_0923-0048 20180831.docx	Form and Instruction
Att1_Blood Lead and Urine Arsenic in Anaconda MT EI SupStatement A - 0923-0048.docx Supporting Statement A	IC Document
Att2_Blood Lead and Urine Arenic in Anaconda MT EI SupStatement B - 0923-0048.docx Supporting Statement B	IC Document
Att3A_Privacy Act Statement_Anaconda EI_0923-0048.docx Privacy Act Statement - Anaconda MT	IC Document
Att3B_Adult Consent Form_Anaconda EI_0923-0048.docx Adult Consent Form	IC Document
Att3C_Parental Permission Form_Anaconda EI_0923-0048.docx Parental Permission Form - Children Younger than 18 Years of Age	IC Document
Att3D_Child Assent Form_Anaconda EI_0923-0048.docx Assent Form - Children Younger than 18 Years of Age	IC Document
Att5_Anaconda EI RDF signed OS.pdf Anaconda MT - Research Determination	IC Document
Att6_Example Results Letter_Anaconda EI_0923-0048.docx Example Results Letter - Anacomnda MT	IC Document
Att8_PIA_Request_0923-0048.pdf Anaconda MT PIA Request	IC Document
Blood Lead Urine Arsenic_Anaconda_EI_GenIC SubmissionForm.docx GenIC submission Form	IC Document
Att9 Anaconda EI Protocol FINAL 20180831.docx Anaconda MT EI Protocol	IC Document
18_CS_295835_ANACONDA POSTCARD.pdf Anaconda MT Testing - Postcard	IC Document

IC Title:

Blood Lead and Urine Arsenic Levels in Anaconda, MT - Exposure Investigation

Agency IC Tracking Number:

0923-0048-18AXF

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	0923-0048	Anaconda MT Exposure Investigation Questionnaire	Att4_Questionnaire_AnacondaEI_0923-0048 20180831.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-19-0001 - Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances

FR Citation: 76 FR 4431

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Att1_Blood Lead and Urine Arsenic in Anaconda MT EI SupStatement A - 0923-0048.docx	08/31/2018
Supporting Statement B	Att2_Blood Lead and Urine Arenic in Anaconda MT EI SupStatement B - 0923-0048.docx	08/31/2018
Privacy Act Statement - Anaconda MT	Att3A_Privacy Act Statement_Anaconda EI_0923-0048.docx	08/31/2018
Adult Consent Form	Att3B_Adult Consent Form_Anaconda EI_0923-0048.docx	08/31/2018
Parental Permission Form - Children Younger than 18 Years of Age	Att3C_Parental Permission Form_Anaconda EI_0923-0048.docx	08/31/2018
Assent Form - Children Younger than 18 Years of Age	Att3D_Child Assent Form_Anaconda EI_0923-0048.docx	08/31/2018
Anaconda MT - Research Determination	Att5_Anaconda EI RDF signed OS.pdf	08/31/2018
Example Results Letter - Anacomnda MT	Att6_Example Results Letter_Anaconda EI_0923-0048.docx	08/31/2018
Anaconda MT PIA Request	Att8_PIA_Request_0923-0048.pdf	08/31/2018
GenIC submission Form	Blood Lead Urine Arsenic_Anaconda_EI_GenIC SubmissionForm.docx	08/31/2018
Anaconda MT EI Protocol	Att9 Anaconda EI Protocol FINAL 20180831.docx	08/31/2018
Anaconda MT Testing - Postcard	18_CS_295835_ANACONDA POSTCARD.pdf	08/31/2018

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