Biomonitoring of Great Lakes Populations Program III

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Follow-Up Survey - Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Network Size Questions for Respondent-driven Sampling - Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Form 0923-0056 Clinic Visit Checklist and Body Measurements - Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Study Questionnaire - Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Contact Information Form for Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Eligibility Screening Survey for Burmese Immigrants and their Descendants	Form and Instruction	Unchanged	Available
Follow-Up Survey for Licensed Anglers	Form and Instruction	Unchanged	Available
Clinic Visit Checklist and Body Measurements - Licensed Anglers	Form and Instruction	Unchanged	Available
Study Questionnaire for Licensed Anglers - Screenshot	Form and Instruction	Unchanged	Available
Study Questionnaire for Licensed Anglers - Paper	Form and Instruction	Unchanged	Available
Eligibility Screening Survey for Licensed Anglers - Screenshot	Form and Instruction	Unchanged	Available
Eligibility Screening Survey for Licensed Anglers (paper) 31OCT2017	Form and Instruction	Modified	Available
0923-0056 Change Request Justification and crosswalk table attm5b.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-10-31	Available
0923-0056 Change Request Justification and crosswalk table.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-07-21	Available
5f.Appointment reminder letters revised.docx	Supplementary Document	Uploaded 2017-07-21	Available
5a.RecruitmentManterial invite letter revised.docx	Supplementary Document	Uploaded 2017-07-21	Available
12b. WI_ResearchDetermination.pdf	Supplementary Document	Uploaded 2017-04-10	Available
12a.ATSDR_ResearchDetermination_GL3.pdf	Supplementary Document	Uploaded 2017-04-10	Available
11.LabSOPcomb_metal_PCB_PFC_PAH.pdf	Supplementary Document	Uploaded 2017-04-10	Available
10b.ResultsPacket.docx	Supplementary Document	Uploaded 2017-04-10	Available
10a.EarlyResults.doc	Supplementary Document	Uploaded 2017-04-10	Available
8d.GiftcardLetter_Burm.docx	Supplementary Document	Uploaded 2017-04-10	Available
8c.RDS_Coupon_Burm.pdf	Supplementary Document	Uploaded 2017-04-10	Available
6b.Consent_Burm.docx	Supplementary Document	Uploaded 2017-04-10	Available
6a.Consent_LicAng.docx	Supplementary Document	Uploaded 2017-04-10	Available
5a.RecruitmentMaterials.pdf	Supplementary Document	Uploaded 2017-04-10	Available
4b.Map.docx	Supplementary Document	Uploaded 2017-04-10	Available
4a.ProgramOverview.docx	Supplementary Document	Uploaded 2017-04-10	Available
3.PublicCommentResponse.docx	Supplementary Document	Uploaded 2017-04-10	Available
2.60dayFederalRegisterNotice.pdf	Supplementary Document	Uploaded 2017-04-10	Available
1.AuthLegislation ATSDR.docx	Supplementary Document	Uploaded 2017-04-10	Available
BGLPP3-SSB.docx	Supporting Statement B	Uploaded 2017-04-10	Available
BGLPP3-SSA 10APR2017.docx	Supporting Statement A	Uploaded 2017-04-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226333	Follow-Up Survey - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Follow-Up Survey - Burmese Immigrants and their Descendants
226332	Network Size Questions - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Network Size Questions for Respondent-driven Sampling - Burmese Immigrants and their Descendants
226331	Clinic Visit and Body Measurements - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Clinic Visit Checklist and Body Measurements - Burmese Immigrants and their Descendants
226330	Study Questionnaire - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Study Questionnaire - Burmese Immigrants and their Descendants
226329	Contact Information Form - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Contact Information Form for Burmese Immigrants and their Descendants
226328	Eligibility Screening Survey - Burmese Immigrants and Descendants	Form and Instruction	Unchanged	Eligibility Screening Survey for Burmese Immigrants and their Descendants
226327	Follow-Up Survey - Licensed Anglers	Form and Instruction	Unchanged	Follow-Up Survey for Licensed Anglers
226326	Clinic Visit Checklist and Body Measurements - Licensed Anglers	Form and Instruction	Unchanged	Clinic Visit Checklist and Body Measurements - Licensed Anglers
226325	Study Questionnaire - Licensed Anglers - Screenshot	Form and Instruction	Unchanged	Study Questionnaire for Licensed Anglers - Screenshot
226324	Study Questionnaire - Licensed Anglers - Paper	Form and Instruction	Unchanged	Study Questionnaire for Licensed Anglers - Paper
226323	Eligibility Screening Survey - Licensed Anglers - Screenshots	Form and Instruction	Unchanged	Eligibility Screening Survey for Licensed Anglers - Screenshot
226321	Eligibility Screening Survey - Licensed Anglers - Paper	Form and Instruction	Modified	Eligibility Screening Survey for Licensed Anglers (paper) 31OCT2017

ICR Details

OMB Control No: 0923-0056	ICR Reference No: 201710-0923-001
Status: Historical Active	Previous ICR Reference No: 201707-0923-001
Agency/Subagency: HHS/TSDR	Agency Tracking No: 0923-0056-18DP
Title: Biomonitoring of Great Lakes Populations Program III
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/16/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/02/2017
Terms of Clearance: Previous terms continue: Approved consistent with the understanding that the core program objective is to provide a current ‘snap shot’ of human exposure levels among susceptible subpopulations living around the Milwaukee AOC. This surveillance project will not investigate health outcomes or biological effects from such exposures. The biomonitoring results will not be generalized beyond the selected AOC and the defined subpopulations under study. The design does not support the ability to draw conclusions about the statistical significance of differences between either the populations being studies or with data from nationally representative populations (e.g., NHANES), as the underlying assumptions in all of these samples are very different.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	07/31/2020	07/31/2020
Responses	731	0	731
Time Burden (Hours)	227	0	227
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this Non-Substantive Change Request is to change the Eligibility Screening Survey for Licensed Anglers, at the suggestion of the Wisconsin Department of Health. Changes to the materials include the layout of the instructional text, the addition of yes/no checkboxes, inviting interested recipients to return the survey (instead of only those who fulfill all eligibility criteria), and a request to add a communication method to schedule appointments. the recruitment letter/postcard (attachment 5a), appointment reminder letters (attachment 5f), and clinic visit checklists (attachments 8a and 8b) per suggestions from WI DHS external information approval reviewers and field clinic.

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Authorizing Statute(s): US Code: 42 USC 9604 Name of Law: CERCLA / SARA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 124	01/03/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 16832	04/06/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Clinic Visit Checklist and Body Measurements - Licensed Anglers	NA	Clinic Visit Checklist and Body Measurements - Licensed Anglers
Clinic Visit and Body Measurements - Burmese Immigrants and Descendants	0923-0056	Clinic Visit Checklist and Body Measurements - Burmese Immigrants and their Descendants
Contact Information Form - Burmese Immigrants and Descendants	NA	Contact Information Form for Burmese Immigrants and their Descendants
Eligibility Screening Survey - Burmese Immigrants and Descendants	NA	Eligibility Screening Survey for Burmese Immigrants and their Descendants
Eligibility Screening Survey - Licensed Anglers - Paper	NA	Eligibility Screening Survey for Licensed Anglers (paper) 31OCT2017
Eligibility Screening Survey - Licensed Anglers - Screenshots	NA	Eligibility Screening Survey for Licensed Anglers - Screenshot
Follow-Up Survey - Burmese Immigrants and Descendants	NA	Follow-Up Survey - Burmese Immigrants and their Descendants
Follow-Up Survey - Licensed Anglers	NA	Follow-Up Survey for Licensed Anglers
Network Size Questions - Burmese Immigrants and Descendants	NA	Network Size Questions for Respondent-driven Sampling - Burmese Immigrants and their Descendants
Study Questionnaire - Burmese Immigrants and Descendants	NA	Study Questionnaire - Burmese Immigrants and their Descendants
Study Questionnaire - Licensed Anglers - Paper	NA	Study Questionnaire for Licensed Anglers - Paper
Study Questionnaire - Licensed Anglers - Screenshot	NA	Study Questionnaire for Licensed Anglers - Screenshot

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	731	731	0	0	0	0
Annual Time Burden (Hours)	227	227	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $633,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/02/2017

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