Information Collection

Environmental Sample Collection Form

IC 233861 under ICR 201907-0923-001 · OMB 0923-0059.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Environmental Sample Collection Form	Form
Environmental Sampling Collection Form PrtApndxC2_EnvSampleCollctnFrm_20190206_clean.docx	Form

IC Title:

Environmental Sample Collection Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	NA	Environmental Sampling Collection Form	PrtApndxC2_EnvSampleCollctnFrm_20190206_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: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	457	457

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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