Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

Forms and Documents

Document	Type	Status	Availability
EA Participants (All Ages) - Biological Testing Tracking	Form	New	Available
Environmental Sample Collection Form	Form	New	Repair queued
Environmental Sampling Consent	Form	New	Available
Household Recruitment Script for Environmental Sampling	Form	New	Repair queued
Exposure Questionnaire for Biological Testing - Child Completed	Form	New	Repair queued
Child Assent	Form	New	Repair queued
Exposure Questionnaire for Biological Testing - Parent Proxy	Form	New	Repair queued
Parental Permission	Form	New	Available
Adult Exposure Assessment Questionnaire	Form	New	Repair queued
Adult Consent	Form	New	Available
Household Eligibility Screener	Form	New	Repair queued
Community Event Evaluation Survey	Form	New	Repair queued
Site Selection Supplement_20190509.docx	Supplementary Document	Uploaded 2019-06-27	Available
PFAS Exposure Assessment Protocol_20190604_clean.docx	Supplementary Document	Uploaded 2019-06-27	Repair queued
PFAS EA SSB_20190501_clean.docx	Supporting Statement B	Uploaded 2019-06-27	Available
PFAS EA SSA_20190524 clean.docx	Supporting Statement A	Uploaded 2019-06-27	Available
PrtApndxG2_RsultsLttrEnviroSmpling 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxG1_RsultsLttrBiolgcSmplng 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Repair queued
PrtApndxE_UrineCollctnInstrctns 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxD_ChainCustodyForms 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Repair queued
PrtApndxI_DataMangmntPlan 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxH_SiteHlthSafetyPlan 20181024.docx	Supplementary Document	Uploaded 2019-06-27	Repair queued
Att6 PFAS EA Research Determination 20180711.pdf	Supplementary Document	Uploaded 2018-11-01	Repair queued
Att5 PIA_PFAS EA signed OCISO 20181001.pdf	Supplementary Document	Uploaded 2018-11-01	Repair queued
Att4 ExmpleEIRprt for PFAS 20161128.pdf	Supplementary Document	Uploaded 2019-06-27	Repair queued
Att3 PFAS Exposure Assessment Technical Tools (PEATT).pdf	Supplementary Document	Uploaded 2019-06-27	Repair queued
Att2a Agency Responses to Public Comments 20181012.pdf	Supplementary Document	Uploaded 2018-11-01	Repair queued
Att2 PFAS EA 60-day FRN 20180719.pdf	Supplementary Document	Uploaded 2018-11-01	Repair queued
Att1 PFAS EA Authorizing Legislation 20181012.pdf	Supplementary Document	Uploaded 2018-11-01	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
236722	EA Participants (All Ages) - Biological Testing Tracking	Form	New
233861	Environmental Sample Collection Form	Form	New
233860	Environmental Sampling Consent	Form	New
233859	Household Recruitment Script for Environmental Sampling	Form	New
233858	Exposure Questionnaire for Biological Testing - Child Completed	Form	New
233857	Child Assent	Form	New
233855	Exposure Questionnaire for Biological Testing - Parent Proxy	Form	New
233853	Parental Permission	Form	New
233852	Adult Exposure Assessment Questionnaire	Form	New
233851	Adult Consent	Form	New
233850	Household Eligibility Screener	Form	New
233849	Community Event Evaluation Survey	Form	New

ICR Details

OMB Control No: 0923-0059	ICR Reference No: 201811-0923-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/TSDR	Agency Tracking No: 0923-18AJK
Title: Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/28/2019
	Date Received in OIRA: 11/29/2018
Terms of Clearance: We appreciate CDC/ATSDR's agreement to the following terms of clearance: Prior to initiating collection at any future sites, ATSDR will provide a detailed site selection supplement similar to the current site supplement but specific to additional study sites for review and approval. Provided that the methodology and data collection are consistent with the approved exposure assessment protocol, the new sites may be included in the package through a non-substantive change request. ATSDR will issue no individual results reports until completion of the interagency scientific review and OMB approves the content and uses of the relevant communication materials.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	8,551	0	0
Time Burden (Hours)	2,131	0	0
Cost Burden (Dollars)	33,029	0	0

---

Abstract: This information collection addresses the requirements for completing exposure assessments (EAs) for PFAS authorized in Section 8006 of the Consolidated Appropriations Act, 2018. ATSDR/NCEH will use statistical methods to recruit respondents at a minimum of eight current or former domestic military installations known to have PFAS contamination in water sources. ATSDR will collect biological and environmental samples to evaluate exposure.

---

Authorizing Statute(s): US Code: 42 USC 9604 Name of Law: CERCLA
   PL: Pub.L. 115 - 141 8006 Name of Law: Consolidated Appropriations Act
   US Code: 42 USC 301 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 34135	07/19/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 60867	11/27/2018
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Exposure Questionnaire for Biological Testing - Child Completed	NA	Exposure Assessment Child
Household Recruitment Script for Environmental Sampling	NA	Household Recruitment Script for Environmental Sampling
Environmental Sampling Consent	NA	Consent for Environmental Sampling
Environmental Sample Collection Form	NA	Environmental Sampling Collection Form
EA Participants (All Ages) - Biological Testing Tracking	NA	FAS EA Biological Testing Tracking Form
Household Eligibility Screener	NA	Household Eligibility Screener
Community Event Evaluation Survey	NA	PFAS Exposure Assessment Community Event Evaluation
Adult Consent	NA	Adult Consent
Adult Exposure Assessment Questionnaire	NA	Adult Exposure Assessment
Parental Permission	NA	Parental Permission Form
Exposure Questionnaire for Biological Testing - Parent Proxy	NA	Exposure Assessment Child
Child Assent	NA	Assent Form for Minors

---

ICR Summary 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	8,551	0	0	8,551	0	0
Annual Time Burden (Hours)	2,131	0	0	2,131	0	0
Annual Cost Burden (Dollars)	33,029	0	0	33,029	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new ICR.

---

Annual Cost to Federal Government: $3,500,000

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.     Yes

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

---

Common Form ICR:  No

---

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: 11/29/2018

---