Information Collection

Identifying Sources of and Risk Factors for Harmful Algal Bloom Exposures through Poison Control Center Follow-up Questionnaires – United States, 2019

IC 237171 under ICR 201609-0920-003 · OMB 0920-1166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1166 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1166 Identifying Sources of and Risk Factors for Harmful Algal Bloom Exposures through Poison Control Center Follow-up Questionnaires – United States, 2019	Form
0920-1166 Follow-up questionnaire for individuals calling poison c SUGGESTED REVISION CLEAN Att2 HABs GenIC Questionnaire - Adult.docx	Form
0920-1166 Follow-up questionnaire for individuals calling poison c SUGGESTED REVISION CLEAN Att3 HABs GenIC Questionnaire - Adolescent.docx	Form
0920-1166 Follow-up questionnaire for individuals calling poison c SUGGESTED REVISION CLEAN Att4 HABs GenIC Questionnaire - Parent-Child.docx	Form
1 - HABs GenIC Rqst Apprvl Form PCCPHE.pdf GenIC Request Approval Form 0920-1166	IC Document
1 - HABS_GenIC_SSB.docx Supporting Statement B	IC Document
Att1 HABs GenIC Consent and Assent Forms.docx Consent - Assent	IC Document
Att5 RDF_HABs GenIC_20190726 signed OS.pdf Research Determination Form	IC Document
Burden Table Memo 0920-1166.msg Burden Table Memo	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Identifying Sources of and Risk Factors for Harmful Algal Bloom Exposures through Poison Control Center Follow-up Questionnaires â United States, 2019

Agency IC Tracking Number:

0920-1166-19BMZ

IC Status: New

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	0920-1166	Follow-up questionnaire for individuals calling poison control centers (PCCs) regarding exposures to harmful algal blooms (HABs) â ADULT	SUGGESTED REVISION CLEAN Att2 HABs GenIC Questionnaire - Adult.docx	NA	Yes	Yes	Fillable Fileable
Form	0920-1166	Follow-up questionnaire for individuals calling poison control centers (PCCs) regarding exposures to harmful algal blooms (HABs) â ADOLESCENT	SUGGESTED REVISION CLEAN Att3 HABs GenIC Questionnaire - Adolescent.docx	NA	Yes	Yes	Fillable Fileable
Form	0920-1166	Follow-up questionnaire for individuals calling poison control centers (PCCs) regarding exposures to harmful algal blooms (HABs) â PARENT-CHILD	SUGGESTED REVISION CLEAN Att4 HABs GenIC Questionnaire - Parent-Child.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request Approval Form 0920-1166	1 - HABs GenIC Rqst Apprvl Form PCCPHE.pdf	07/30/2019
Supporting Statement B	1 - HABS_GenIC_SSB.docx	07/30/2019
Consent - Assent	Att1 HABs GenIC Consent and Assent Forms.docx	07/30/2019
Research Determination Form	Att5 RDF_HABs GenIC_20190726 signed OS.pdf	07/30/2019
Burden Table Memo	Burden Table Memo 0920-1166.msg	07/30/2019

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