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

ATSDR Exposure Investigations (EIs)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.