Information Collection

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

IC 233661 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⚠️ Notice: This information collection may be referencing outdated material.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: Anaconda EI II	Form and Instruction
0923-0048 Anaconda MT Exposure Investigation II - Participant Ques Att4_Questionnaire_ Anaconda EI II - 0923-0048 OS.docx	Form and Instruction
Anaconda_EI_II_GenIC SubmissionForm.docx 0923-0048 GenIC Submission Form	IC Document
Att3A_Privacy Act Statement_Anaconda EI_II 0923-0048.docx Privacy Act Statement	IC Document
Att3B_Adult Consent Form_Anaconda EI_II_0923-0048.docx Adult Consent Form	IC Document
Att3C_Parental Permission Form_Anaconda EI_II_0923-0048.docx Parental Permission Form - Children under 18 Years of Age	IC Document
Att3D_Child Assent Form_Anaconda EI II - 0923-0048.docx Child Assent Form - Children between 7-17 Years of Age	IC Document
Att5__Anaconda EI II RDF signed OS.pdf Human Subjects Research Determination Form	IC Document
Att6_Example REsults Letter_Anaconda MT EI II - 0923-0048.docx Example Results Letter	IC Document
Att7_EI Report Example_Former United Zinc EI (final) _ 08-15-2018.pdf Exposure Investigation Report (Example: FORMER UNITED ZINC & ASSOCIATED SMELTERS - Iola, Kansas)	IC Document
Att8_PIA_Requests_Anaconda EI II_0923-0048.pdf Privacy Impact Assessment	IC Document
Att9 Anaconda EI II Protocol_final 0923-0048.docx Exposure Investigation Protocol	IC Document
Att1_Anaconda MT EI II SupStatement A - 0923-0048.docx Supporting Statement A	IC Document
Att2_Anaconda MT EI II SupStatement B - 0923-0048.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

0923-0048-19BV

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 II - Participant Questionnaire and Sample Collection	Att4_Questionnaire_ Anaconda EI II - 0923-0048 OS.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: 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	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0923-0048 GenIC Submission Form	Anaconda_EI_II_GenIC SubmissionForm.docx	10/22/2018
Privacy Act Statement	Att3A_Privacy Act Statement_Anaconda EI_II 0923-0048.docx	10/22/2018
Adult Consent Form	Att3B_Adult Consent Form_Anaconda EI_II_0923-0048.docx	10/22/2018
Parental Permission Form - Children under 18 Years of Age	Att3C_Parental Permission Form_Anaconda EI_II_0923-0048.docx	10/22/2018
Child Assent Form - Children between 7-17 Years of Age	Att3D_Child Assent Form_Anaconda EI II - 0923-0048.docx	10/22/2018
Human Subjects Research Determination Form	Att5__Anaconda EI II RDF signed OS.pdf	10/22/2018
Example Results Letter	Att6_Example REsults Letter_Anaconda MT EI II - 0923-0048.docx	10/22/2018
Exposure Investigation Report (Example: FORMER UNITED ZINC & ASSOCIATED SMELTERS - Iola, Kansas)	Att7_EI Report Example_Former United Zinc EI (final) _ 08-15-2018.pdf	10/22/2018
Privacy Impact Assessment	Att8_PIA_Requests_Anaconda EI II_0923-0048.pdf	10/22/2018
Exposure Investigation Protocol	Att9 Anaconda EI II Protocol_final 0923-0048.docx	10/22/2018
Supporting Statement A	Att1_Anaconda MT EI II SupStatement A - 0923-0048.docx	10/22/2018
Supporting Statement B	Att2_Anaconda MT EI II SupStatement B - 0923-0048.docx	10/22/2018

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