Information Collection

Flint Rash Investigation

IC 220237 under ICR 201607-0923-002 · OMB 0923-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0051 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Flint Rash Investigation	Form and Instruction
Self-reported Rash Symptoms and Exposure - MDHHS Questio AttB Flint Questionnaire 20160224 MDHHS clean.docx	Form and Instruction
Flint Medical Chart Abstraction AttC Flint Medical Chart Abstraction Form 20160224.docx	Form
Request ACE Investsgtn Form_Flint Rash Investigation 20160224 MDHHS clean.pdf Request for Approval	IC Document
AttA Flint Rash Investigation State Request 20160223.pdf Invitation from Michigan	IC Document
ACE Supporting Statement B_Flint Rash Investigation 20160224.docx Supporting Statement B	IC Document
AttD Flint Rash Investigation Research Determination 20160224.pdf Research Determination	IC Document

IC Title:

Flint Rash Investigation

Agency IC Tracking Number:

16RV

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	none	Self-reported Rash Symptoms and Exposure - MDHHS Questionnaire	AttB Flint Questionnaire 20160224 MDHHS clean.docx		No		Paper Only
Form	none	Flint Medical Chart Abstraction	AttC Flint Medical Chart Abstraction Form 20160224.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	Request ACE Investsgtn Form_Flint Rash Investigation 20160224 MDHHS clean.pdf	02/25/2016
Invitation from Michigan	AttA Flint Rash Investigation State Request 20160223.pdf	02/25/2016
Supporting Statement B	ACE Supporting Statement B_Flint Rash Investigation 20160224.docx	02/25/2016
Research Determination	AttD Flint Rash Investigation Research Determination 20160224.pdf	02/25/2016

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