Information Collection

Supplemental Exposure Investigation at Select PFAS Exposure Assessment Sites

IC 251672 under ICR 201901-0923-001 · OMB 0923-0048.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0048 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0048 Supplemental Exposure Investigation at Select PFAS Exposure Assessment Sites	Form and Instruction
0923-0048 Household Recruitment Script Att7_ApxA2_Recruitment Scripts.docx	Form and Instruction
0923-0048 Household Questionnaire - Adult (Dust Only) Att14_ApxC1_Household Quest _ FINAL.docx	Form and Instruction
0923-0048 Personal Exposure Questionnaire - Adult (Dust Only) Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	Form and Instruction
0923-0048 Environmental Sampling Collection Form - Adult (Dust Onl Att18_ApxD1_PFAS Sampling Coll Form _Dust.docx	Form and Instruction
0923-0048 Household Questionnaire - Adult (Robust) Att14_ApxC1_Household Quest _ FINAL.docx	Form and Instruction
0923-0048 Personal Exposure Questionnaire - Adult (Robust) Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	Form and Instruction
0923-0048 Environmental Sampling Collection Form - Adult (Robust) Att19_ApxD2_PFAS Sampling Coll Form_Robust _ FINAL.docx	Form and Instruction
0923-0048 Personal Exposure Questionnaire - Adult Consent (Self On Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	Form and Instruction
0923-0048 Personal Exposure Questionnaire - Child (12-17 Years) Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx	Form and Instruction
0923-0048 Personal Exposure Questionnaire - Child (Less than 12) Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx	Form and Instruction
0 - GenIC SubmssnFrm_SupplmntlPFAS_EI.docx 0923-0048 GenIC Submission Form	IC Document
Att1_PFAS Environ Sampling EI SSA - 0923-0048_FINAL.docx Supporting Statement A	IC Document
Att2_PFAS Environ Sampling EI SSB - 0923-0048 FINAL .docx Supporting Statement B	IC Document
Att5_PFAS Environ Sampling EI Protocol _ FINAL .docx Environmental Sampling Protocol	IC Document
Att6_Apx A1_Household Recruitment Letter .docx Household Recruitment Letter	IC Document
Att8_ApxA3_Appt Verification Letter.docx Appointment Verification Letter	IC Document
Att10_ApxB2_Adult Consent1.docx Adult Consent 1	IC Document
Att11_ApxB3_Adult Consent2.docx Adult Consent 2	IC Document
Att12_ApxB4_Parental Permission.docx Parental Permission	IC Document
Att13_ApxB5_Assent Form.docx Assent Form	IC Document
Att17_ApxD_SAP_FINAL.docx Sampling and Analysis Plan (SAP)	IC Document
Att20_ApxE_H&S Plan.docx Health and Safety Plan	IC Document
Att21_ApxF1_Results Letter_dust only.docx Results Letter - Dust Only	IC Document
Att22_ApxF2_Results Letter_Robust.docx Results Letter - Robust	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Supplemental Exposure Investigation at Select PFAS Exposure Assessment Sites

Agency IC Tracking Number:

0923-0048-21GQ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0923-0048	Household Recruitment Script	Att7_ApxA2_Recruitment Scripts.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Household Questionnaire - Adult (Dust Only)	Att14_ApxC1_Household Quest _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Personal Exposure Questionnaire - Adult (Dust Only)	Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Environmental Sampling Collection Form - Adult (Dust Only)	Att18_ApxD1_PFAS Sampling Coll Form _Dust.docx	NA	No		Paper Only
Form and Instruction	0923-0048	Household Questionnaire - Adult (Robust)	Att14_ApxC1_Household Quest _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Personal Exposure Questionnaire - Adult (Robust)	Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Environmental Sampling Collection Form - Adult (Robust)	Att19_ApxD2_PFAS Sampling Coll Form_Robust _ FINAL.docx	NA	No		Paper Only
Form and Instruction	0923-0048	Personal Exposure Questionnaire - Adult Consent (Self Only)	Att15_ApxC2_Personal Exp Quest_Adult _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Personal Exposure Questionnaire - Child (12-17 Years)	Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0923-0048	Personal Exposure Questionnaire - Child (Less than 12)	Att16_ApxC3_Personal Exp Quest_Child _ FINAL.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-19-0001 - Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4431

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 55 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	351	351
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0923-0048 GenIC Submission Form	0 - GenIC SubmssnFrm_SupplmntlPFAS_EI.docx	02/17/2022
Supporting Statement A	Att1_PFAS Environ Sampling EI SSA - 0923-0048_FINAL.docx	02/17/2022
Supporting Statement B	Att2_PFAS Environ Sampling EI SSB - 0923-0048 FINAL .docx	02/17/2022
Environmental Sampling Protocol	Att5_PFAS Environ Sampling EI Protocol _ FINAL .docx	02/17/2022
Household Recruitment Letter	Att6_Apx A1_Household Recruitment Letter .docx	02/17/2022
Appointment Verification Letter	Att8_ApxA3_Appt Verification Letter.docx	02/17/2022
Adult Consent 1	Att10_ApxB2_Adult Consent1.docx	02/17/2022
Adult Consent 2	Att11_ApxB3_Adult Consent2.docx	02/17/2022
Parental Permission	Att12_ApxB4_Parental Permission.docx	02/17/2022
Assent Form	Att13_ApxB5_Assent Form.docx	02/17/2022
Sampling and Analysis Plan (SAP)	Att17_ApxD_SAP_FINAL.docx	02/17/2022
Health and Safety Plan	Att20_ApxE_H&S Plan.docx	02/17/2022
Results Letter - Dust Only	Att21_ApxF1_Results Letter_dust only.docx	02/17/2022
Results Letter - Robust	Att22_ApxF2_Results Letter_Robust.docx	02/17/2022

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