Assessment of Potential Exposure from Private Wells for Drinking Water

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1173 Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction	New	Available
AttJ Example Instructions for Urine and Water 3-17-16 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttI Example Questionnaire 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttH Example Consent Form 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttG Example Screening Form 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttF Example Recruiting Flyer Letter 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttE Privacy Impact Assessment 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Repair queued
AttC Instructions Generic ICR 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttB1 PblcCommnts Agncy Respnse 3-17-17 CLEAN.docx	Supplementary Document	Uploaded 2017-03-30	Available
AttK Private Wells Burden Memo 6-1-16.docx	Supplementary Document	Uploaded 2016-06-22	Available
AttJ Research Determination Form 6-1-16.pdf	Supplementary Document	Uploaded 2016-06-22	Available
AttI Example Instructions for Urine and Water CLEAN 3-3-16.docx	Supplementary Document	Uploaded 2016-06-22	Available
AttH Example Questionnaire 6-1-16.docx	Supplementary Document	Uploaded 2016-06-22	Available
AttG Example Consent Form 6-1-16.docx	Supplementary Document	Uploaded 2016-06-22	Available
AttF Example Screening Form Clean 6-1-16.docx	Supplementary Document	Uploaded 2016-06-22	Repair queued
AttE Example Recruiting Flyer Letter 6-1-16.doc	Supplementary Document	Uploaded 2016-06-22	Available
AttD Request Approval Generic ICR 6-1-16.docx	Supplementary Document	Uploaded 2016-06-09	Available
AttC Instructions Generic Clearance 6-1-16.docx	Supplementary Document	Uploaded 2016-06-09	Available
AttB1 PblcCommnts Agncy Respnse 6-1-16.docx	Supplementary Document	Uploaded 2016-06-09	Available
AttB 60-day FRN 20160311.pdf	Supplementary Document	Uploaded 2016-06-09	Available
AttA_Public Health Service Act Section 301 3-2-16.docx	Supplementary Document	Uploaded 2016-06-09	Available
SSB Private Wells 3-17-17 CLEAN.docx	Supporting Statement B	Uploaded 2017-03-30	Available
SSA Private Wells 3-17-17 CLEAN.docx	Supporting Statement A	Uploaded 2017-03-30	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237560	Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction	New

ICR Details

OMB Control No: 0920-1173	ICR Reference No: 201606-0920-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-16TL
Title: Assessment of Potential Exposure from Private Wells for Drinking Water
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/30/2017
	Date Received in OIRA: 06/23/2016
Terms of Clearance: Approved consistent with the understanding that collections submitted under this generic are not considered research and will not include epidemiological studies or the collection of health data. Each GenIC will include a full supporting statement Part A and B.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved
Responses	19,500	0	0
Time Burden (Hours)	6,252	0	0
Cost Burden (Dollars)	141,987	0	0

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Abstract: There is no comprehensive knowledge about the locations of private wells, the populations served by these sources, potential contaminants that might be present in private well water in specific areas of the country, or the potential health risks associated with drinking water from these sources. The goal of this generic clearance information collection request (Generic ICR) is to expedite investigations of private well water for drinking in response to specific investigation requests. Each investigation will assess exposure to contaminants in drinking water from private wells in a geographic area specified by the requesting entity. Requesting entities may be any state, territorial, local, or tribal health department in the United States. Methods to collect data include questionnaires and analysis of clinical specimens and/or environmental samples.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 12902	03/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 40703	06/22/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	0920-1173, 0920-1173, 0920-1173, 0920-1173	Screening Survey ,   Consent Form ,   Food and Bathing Log ,   Survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	19,500	0	0	19,500	0	0
Annual Time Burden (Hours)	6,252	0	0	6,252	0	0
Annual Cost Burden (Dollars)	141,987	0	0	141,987	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Submission of 0920-16TL is a New Generic ICR. Burden values reflect Total Responses and Burden Hours for period of three years.

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Annual Cost to Federal Government: $441,200

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/23/2016

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