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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Form 0920-1173 Exposure to Arsenic and Uranium in Private Well Water in Connecticut New Mexico and New Hampshire Form
AttF_Urine Collection Directions.docx Instruction
0920-1173 Screening Survey AttC_Screening Survey.docx Form
0920-1173 Food and Bathing Log AttE_FoodandBathing Log.docx Form and Instruction
0920-1173 Survey (Exposure to Arsenic an Uranium in Private Well W AttG_Survey.docx Form
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
AttA_Letters of Collaboration.pdf Att A_Letters of Collaborations IC Document
AttB_Invitation Letter.docx Att B_Invitation Letter IC Document
AttD_Consent Form.docx Att D_Consent Form IC Document
AttH_Participant Results Letter.docx Att H_Participant Result Letter IC Document
AttI_Research Determination Form.pdf Att I_Research Determination Form IC Document

Information Collection (IC) Details

IC Title:	Exposure to Arsenic and Uranium in Private Well Water in Connecticut New Mexico and New Hampshire	Agency IC Tracking Number:	0920-1173-19BGI

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	0920-1173	Screening Survey	AttC_Screening Survey.docx	No	Fillable Fileable
Form and Instruction	0920-1173	Food and Bathing Log	AttE_FoodandBathing Log.docx	No	Fillable Fileable
Instruction			AttF_Urine Collection Directions.docx	No	Paper Only
Form	0920-1173	Survey (Exposure to Arsenic an Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	AttG_Survey.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA	SSA_Exposure to Arsenic and Uranium in Private Well Water.docx	06/12/2019
SSB	SSB_Exposure to Arsenic and Uranium in Private Well Water.docx	06/12/2019
Att A_Letters of Collaborations	AttA_Letters of Collaboration.pdf	06/12/2019
Att B_Invitation Letter	AttB_Invitation Letter.docx	06/12/2019
Att D_Consent Form	AttD_Consent Form.docx	06/12/2019
Att H_Participant Result Letter	AttH_Participant Results Letter.docx	06/12/2019
Att I_Research Determination Form	AttI_Research Determination Form.pdf	06/12/2019

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