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

Poison Center Collaborations for Public Health Emergencies

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

IC Title:	Identifying Sources of and Risk Factors for Harmful Algal Bloom Exposures through Poison Control Center Follow-up Questionnaires – United States, 2019	Agency IC Tracking Number:	0920-1166-19BMZ

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

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 %

	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

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.