Information Collection

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire

IC 237560 under ICR 201606-0920-005 · OMB 0920-1173.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1173 can be found here:

2020-03-23 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1173 Screening Survey Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction
Form 0920-1173 Consent Form Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction
Form 0920-1173 Food and Bathing Log Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction
Form 0920-1173 Survey Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction
0920-1173 Screening Survey AttC_Screening Survey.docx	Form and Instruction
0920-1173 Consent Form AttD_Consent Form.docx	Form and Instruction
0920-1173 Food and Bathing Log AttE_FoodandBathing Log.docx	Form and Instruction
0920-1173 Survey AttG_Survey_OMBrevisions_clean.docx	Form and Instruction
AttA_Letters of Collaboration.pdf Letters of Collaboration	IC Document
AttB_Invitation Letter.docx Invitation Letter	IC Document
AttF_Urine Collection Directions.docx Urine Collection Directions	IC Document
AttH_Participant Results Letter_OMBrevisions_20190820 tracked changes omb.docx Results Letter	IC Document
AttI_Research Determination Form.pdf Research Determination Form	IC Document
Request to use Generic Clearance Form.docx Request for Generic Clearance Form	IC Document
SSA_Exposure to Arsenic and Uranium in Private Well Water.docx SSA	IC Document
SSB_Exposure to Arsenic and Uranium in Private Well Water.docx SSB	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire

Agency IC Tracking Number:

0920-1173-19BLL

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	0920-1173	No	Fillable Fileable
Form and Instruction	0920-1173	No	Fillable Fileable
Form and Instruction	0920-1173	No	Fillable Fileable
Form and Instruction	0920-1173	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 1,900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,900	1,900
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letters of Collaboration		08/27/2019
Invitation Letter		08/27/2019
Urine Collection Directions		08/27/2019
Results Letter		08/27/2019
Research Determination Form		08/27/2019
Request for Generic Clearance Form		08/27/2019
SSA		08/27/2019
SSB		08/27/2019

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

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