Eligibility Screening - Adult/Adolescent Field Users

Characterization of Exposure Potential during Activities Conducted on Synthetic Turf with Crumb Rubber Infill

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0058 can be found here:

Documents and Forms

Document Name Document Type
Eligibility Screening - Adult/Adolescent Field Users Form and Instruction
Field User Eligibility Screening Script Att4b Field User Eligibility Screening Script_Final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screening - Adult/Adolescent Field Users	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	none	Field User Eligibility Screening Script	Att4b Field User Eligibility Screening Script_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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: 41	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	41	41
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	25	25

Documents for IC

Title	Document	Date Uploaded
No associated records found

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