Exposure Questionnaire for Biological Testing - Parent Proxy

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0059 can be found here:

Documents and Forms

Document Name Document Type
Exposure Questionnaire for Biological Testing - Parent Proxy Form
Exposure Assessment Child PrtApndxF PFAS EAs Adult Child ExpAssmntQstnnre_20190524_clean.docx Form
PrtApndxC1_BloodCollctnLog 20181012.docx Biological Sample Collection Log IC Document

Information Collection (IC) Details

IC Title:	Exposure Questionnaire for Biological Testing - Parent Proxy	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	NA	Exposure Assessment Child	PrtApndxF PFAS EAs Adult Child ExpAssmntQstnnre_20190524_clean.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 275	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	275	275
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	1,675	1,675

Documents for IC

Title	Document	Date Uploaded
Biological Sample Collection Log	PrtApndxC1_BloodCollctnLog 20181012.docx	11/01/2018

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