Assessment of Chemical Exposures (ACE) Investigations - FY2016 Q2 Burden Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Follow-Up Flint Rash Dermatology Report Form	Form and Instruction	Unchanged	Available
Flint Medical Chart Abstraction	Form	Unchanged	Available
Self-reported Rash Symptoms and Exposure - MDHHS Questionnaire	Form and Instruction	Unchanged	Available
ACE General Survey Methyl Bromide FINAL	Form and Instruction	Unchanged	Available
ACE Adult/Child/Pet Survey	Form and Instruction	Unchanged	Available
Attachment F_ACE Investigations Burden Memo.docx	Supplementary Document	Uploaded 2016-07-20	Available
0923-0051 Change Request Justification FY2016 Q3.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-07-20	Available
Attachment E_Flint Medical Chart Abstraction Form-final.docx	Supplementary Document	Uploaded 2016-07-20	Available
Attachment B_Flint Rash Dermatology Follow Up Report Form-final.docx	Supplementary Document	Uploaded 2016-07-20	Available
Attachment B_Flint Questionnaire-final.doc	Supplementary Document	Uploaded 2016-07-20	Available
0923-0051 Change Request Justification FY2015 Q3.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-09-10	Available
Attachment B_General Survey_Methyl Bromide_FINAL ADULT_4-7-2015.docx	Supplementary Document	Uploaded 2015-09-10	Available
Attachment D_ACE Survey Consent Form_Methyl Bromide_Final.docx	Supplementary Document	Uploaded 2015-09-10	Available
Attachment F. ACE Burden Memo_Methyl Bromide.docx	Supplementary Document	Uploaded 2015-09-10	Available
Att I NCEH-ATSDR Research Determination ACE.pdf	Supplementary Document	Uploaded 2015-03-05	Available
Att H ACE Consent Forms_SAMPLE _Clean.docx	Supplementary Document	Uploaded 2015-03-05	Repair queued
Att C MMWR ChlorExp MetalRecyclngFacility_SAMPLE.pdf	Supplementary Document	Uploaded 2015-03-05	Available
Appx 8 Decision Tree for ACE Investigations.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 7 VetChartAbstrct Form_SAMPLE.docx	Supplementary Document	Uploaded 2015-03-05	Available
Att G Steps for Using Generic Clearance for ACE _Clean March 2 2015.docx	Supplementary Document	Uploaded 2015-03-05	Available
Att F ACE Burden Memo.docx	Supplementary Document	Uploaded 2015-03-05	Available
Att E ACE Investigation GenIC Advance Notification Email _Clean March 2 2015.docx	Supplementary Document	Uploaded 2015-03-05	Available
Att D Request ACE Investsgtn Form_March 2 2015 Clean.docx	Supplementary Document	Uploaded 2015-03-05	Available
Att B 60-day FRN 5272014.pdf	Supplementary Document	Uploaded 2014-09-22	Available
Att A AuthLegisl-Combined .docx	Supplementary Document	Uploaded 2014-09-22	Available
Appx 6 MedChartAbstrct Form_SAMPLE_Clean.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 5 HospSurvey_SAMPLE_Clean March 2015.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 4 HHSurvey_SAMPLE_March 2_Clean.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 3 RRR Form_SAMPLE.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 2 GenSurvey_SAMPLE_March 2_Clean.docx	Supplementary Document	Uploaded 2015-03-05	Available
Appx 1 Past ACE Investigations.docx	Supplementary Document	Uploaded 2015-03-05	Available
ACE Supporting Statement B Clean OMB_March 2 2015.docx	Supporting Statement B	Uploaded 2015-03-05	Available
ACE Supporting Statement A_Clean March 2.docx	Supporting Statement A	Uploaded 2015-03-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221128	Flint Rash Investigation	Form and Instruction	Unchanged	Follow-Up Flint Rash Dermatology Report Form
220237	Flint Rash Investigation	Form	Unchanged	Flint Medical Chart Abstraction
220237	Flint Rash Investigation	Form and Instruction	Unchanged	Self-reported Rash Symptoms and Exposure - MDHHS Questionnaire
215956	Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands	Form and Instruction	Unchanged	ACE General Survey Methyl Bromide FINAL
215956	Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands	Form and Instruction	Unchanged	ACE Adult/Child/Pet Survey

ICR Details

OMB Control No: 0923-0051	ICR Reference No: 201607-0923-002
Status: Historical Active	Previous ICR Reference No: 201509-0923-002
Agency/Subagency: HHS/TSDR	Agency Tracking No: 16AVA
Title: Assessment of Chemical Exposures (ACE) Investigations - FY2016 Q2 Burden Report
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/21/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/21/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2018	03/31/2018	03/31/2018
Responses	3,870	0	3,870
Time Burden (Hours)	1,773	0	1,773
Cost Burden (Dollars)	0	0	0

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Abstract: Supporting effective epidemiologic investigations is an important way that ATSDR serves to protect the health of the public. In order for an ACE investigation to occur, the following criteria must be met: 1) ACE investigations will be undertaken at the request of, and in collaboration with, the state, regional, local, or tribal health department (the requesting agency) where the release occurred. 2) ACE investigations will be carried out in the event of an acute chemical release of toxic substances. 3) ACE investigations will be non research public health responses that are designed to prevent or control disease or injury and improve public health 4) ACE investigations will be restricted to domestic incidents. 5) ACE investigations will be completed within 180 days after OMB approval. ATSDR seeks approval for this Generic ICR to ensure that the agency is poised to mobilize quickly when urgent epidemiologic support is requested by our partners. Therefore, ATSDR requests 72-hour approval, or more quickly if needed.

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Authorizing Statute(s): US Code: 42 USC 9626 Name of Law: Superfund Amendments and Reauthorization Act of 1986
   US Code: 42 USC 241 Name of Law: Public Health Service Act
   US Code: 42 USC 9604 Name of Law: Comprehensive Environmental Response, Compensation and Liability Act of 1980
  

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:
	79 FR 30146	05/27/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57108	09/24/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Flint Rash Investigation	NA	Follow-Up Flint Rash Dermatology Report Form
Flint Rash Investigation	none, none	Self-reported Rash Symptoms and Exposure - MDHHS Questionnaire ,   Flint Medical Chart Abstraction
Methyl Bromide Release at a Condominium Resort - U.S. Virgin Islands	None, NA	ACE Adult/Child/Pet Survey ,   ACE General Survey Methyl Bromide FINAL

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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	3,870	3,870	0	0	0	0
Annual Time Burden (Hours)	1,773	1,773	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: Submission is a NEW Generic IC.

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Annual Cost to Federal Government: $41,196

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: 07/21/2016

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