Environmental Sampling Collection Form

Appendix C2: Environmental Sample Collection Form

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

Environmental Sample Collection Form

ATSDR estimates the average public reporting burden for this collection of information as 15 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).

EA ID: ______________________________________________________

Date and time of Sample Collection: ______________________________________

Address of Sample Collection: ___________________________________

Notes:

Samples Collected:

Tap Water – Sample ID ________________________________________________________

Tap Water Sample Location Description ___________________________________________

Tap Water 2 – Sample ID ________________________________________________________

Tap Water 2 Sample Location Description ___________________________________________

Tap Water Blank – Sample ID ___________________________________________________

Indoor Dust – Sample ID _______________________________________________________

Indoor Dust Sample Location Description __________________________________________

Indoor Dust Blank – Sample ID __________________________________________________

Data Collection Technician: ____________________________ ________________________________

Printed Name Signature

Location of Samples Inside the Home: