Att 5c_ATSDR Site Impact Assessment 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 7 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 Site Impact Assessment Form
Each year, ATSDR reports information on the impact of our program to Congress. This information is also useful for describing the work of
our program to other stakeholders and partners.
For HQ sites, each site team (health assessor, health educator, regional office, team lead) will fill out a questionnaire for each document
released in FY 2014 and later. For state documents, the TPO will work with the state coop staff to fill out the questionnaire. The reviewer
selected in the last field will receive a copy of this form to review and approve. Please Contact Matt Sones with any questions.

Site Background Information
Site Name (Use official name of site):
Certified or Non­certified Document:

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Type of Document (Choose one):

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Cooperative Agreement partner:
(Check box if document was written by a cooperative agreement partner)
Choose Safe Places for Early Childcare and Education (CSPECE):
(Check box if document is related to CSPECE program)
Document Title:
Street Address (if there is no specific address, type in "none"):
City where site is located:
State where site is located:

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Zip Code:
EPA Facility ID: (if known)
Cost Recovery #: (enter generic code if no site­specific code is available)

Document Release Date:
Lead Health Assessor:
Lead Health Educator: (if applicable)

Agency Activities and Document Conclusions
Other information about the site (check all that apply):

Who we worked with at this site (check all that apply):

Number of people assessed:
Number of people with exposures that may increase the potential for health effects:
Number of people with potential exposures that could increase the potential for health 
effects:
Primary contaminant assessed at the site: (Choose only one from the list of 10. If your 
primary contaminant is not one of these 10, choose "other".)
Number of people   Number of people with  Number of people with potential 
assessed by pathway: exposures that may  exposures that could increase the 
increase the potential 
potential for health effects by
for health effects by
pathway:
pathway:

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Hazard Category by pathway 
(choose one ­ required!):

Water Pathway

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Air Pathway

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Soil Pathway

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Biota Pathway

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Physical Hazards

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(enter numbers of people for each box, if applicable)

Number of People Protected by ATSDR and Partner Actions
Insert documented or estimated numbers for all fields that apply.
Total number of people protected:

WATER PATHWAY
Number of people protected by new water treatment systems:
Number of water treatment systems installed:
Number of people receiving alternate drinking water:
Number of people protected by surface water access restrictions or remediation:
Number of people protected by groundwater remediation:
Number of people impacted by reductions in water contaminant emissions from an active 
facility:
Number of enforcement actions supported:
Number of people with reduced or stopped exposures to water contaminants due to health
education activities:
Number of people protected by other actions to reduce exposures to contaminated water:
If other actions, then please specify what these actions were:
Total number of people protected in the water pathway:

AIR PATHWAY
Number of people served by vapor mitigation systems:
Number of vapor mitigations systems installed:
Number of people impacted by reductions in air contaminant emissions from an active 
facility:

Number of air enforcement actions supported:
Number of people protected from air exposures by access restrictions:
Number of people with reduced or stopped exposures to air contaminants due to health
education activities:
Number of people protected by other actions to reduce exposures to contaminants in air:
If other actions, then please specify what these actions were:
Total number of people protected in the air pathway:

SOIL PATHWAY
Number of people protected by soil replacement:
Number of yards with soil replacement:
Number of recreational areas with soil replacement:
Number of people protected by access restrictions:
Number of people with reduced or stopped exposures to soil contaminants due to health
education activities:
Number of people protected by capping or other action:
If other actions, then please specify what these actions were:
Total number of people protected in the soil pathway:

BIOTA PATHWAY
Number of people protected by fish (or other biota) advisories:
Number of people educated on safe ways to raise and consume biota:
Total number of people protected in the biota pathway:

PHYSICAL HAZARDS
Number of people protected from physical hazard removal:
Number of people protected by access restrictions:
Number of people protected from physical hazards due to health education activities:
Total number of people protected from physical hazards:

NO HAZARD
Number of people reassured that their air, water, soil, or biota are not causing harmful 
exposures:

Follow­up Information
Have all needed steps been taken to eliminate health risks (or reduce as much as possible)?
If 'No' please describe any outstanding actions or recommendations:

If 'Yes', please check the measures that you used to determine that health risks have been 
reduced or eliminated:

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Did ATSDR recommend additional sampling or monitoring? If so, has follow­up sampling or 
monitoring been conducted?

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Enter additional comments or clarifications here:

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(

Choose reviewer for this form (usually branch chief or TPO):

*Use the address book browse feature to search for the person's name ­ search last name only or "last name, first name" format for best results!* 
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