Activity 2 - Eligibility Screening Script (Adult/Adolescent Facility Users)

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0054 can be found here:

Documents and Forms

Document Name Document Type
Activity 2 - Eligibility Screening Script (Adult/Adolescent Facility Users) Form and Instruction
Activity 2 - Eligibility Screening Script (Adult/Adolesc Att5b Field User Eligibility Screening Script_20160716 clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Activity 2 - Eligibility Screening Script (Adult/Adolescent Facility Users)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Activity 2 - Eligibility Screening Script (Adult/Adolescent Facility Users)	Att5b Field User Eligibility Screening Script_20160716 clean.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-19-0001 Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 57 FR 62814

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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