Att 5b_ATSDR Technical Assistance (TA) Activity Form

Form Approved
OMB Control Number: 0923-xxxx
Expiration Date: xx/xx/201x
ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response,
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the
data/information needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

ATSDR Technical Assistance (TA) Activity Form
This form should be used to capture technical assistance activities provided to internal and
external stakeholders. TA activities should not have any conclusions on data or make a health
call. (conclusions on data should be captured in LHC, HC or PHA products). For more
information on what type of activity is appropriate to capture on this TA form, please see "DCHI
Document Definitions".

Background Information
TA Activity Name:
Non Site­specific? (Check box if the TA is NOT for a site)
Cooperative Agreement Partner? (If yes, check the box)
Is this activity related to the Choose Safe Places for Early
Childcare and Education program? (If yes, check the box)
Site Name:
Street Address (if applicable):
City (if applicable):
State:

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Zip Code (if applicable):
EPA Facility ID (if applicable):
Cost Recovery # (if applicable):
Choose name of TA preparer:

Request Information
Date TA activity was requested:
Who requested the assistance?
Please summarize the question or assistance requested:

*Do not include any confidential information such as private citizen names*
Check all that apply to this request:

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Please specify the "other" that was chosen above:

Response Information
Date of Response or Activity:
Please summarize the response or assistance that was provided for the request:

File Attachment

Collaborations (who we supported) (check all that apply):

Choose Reviewer for this TA ­ a copy of this TA will
be emailed to the reviewer you choose when you
click submit below.
(State partners should choose TPO, ATSDR staff should
choose team lead or branch chief)

Submit to Reviewer
(Note: clicking "save" at the top of this form will just save the form to SharePoint. Clicking "submit to
reviewer" will save the form to SharePoint AND send it to the reviewer chosen above.