OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 236443 under ICR 201606-0920-007 · OMB 0920-0974.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 0920-1173
Screening Survey Exposure to Arsenic and Uranium in Private Well Water in Connecticut New Mexico and New Hampshire		 Form
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 an Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire 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

View Information Collection (IC)

layout table

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 0920-1173 No   Fillable Fileable
Form and Instruction 0920-1173 No   Fillable Fileable
Instruction No   Paper Only
Form 0920-1173 No   Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,200 0 1,200 0 0 0
Annual IC Time Burden (Hours) 150 0 150 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
SSA 06/12/2019
SSB 06/12/2019
Att A_Letters of Collaborations 06/12/2019
Att B_Invitation Letter 06/12/2019
Att D_Consent Form 06/12/2019
Att H_Participant Result Letter 06/12/2019
Att I_Research Determination Form 06/12/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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