Information Collection Request

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

ICR 201908-0923-001 · OMB 0923-0061 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Medical Record Abstraction - Child Form Modified Available
Medical Record Abstraction - Adult Form Modified Available
Child School Record Abstraction Form Modified Available
Child Questionnaire - Short Form Form Modified Available
Child Questionnaire - Long Form Form Modified Available
Adult Questionnaire Form Modified Available
Blood Draw and Urine Collection Form Form Modified Available
Body and Blood Pressure Measures Form Form Modified Available
Medication List Form Modified Available
Update Contact Information Hardcopy Form Form Modified Available
Appointment Reminder Telephone Script Form and Instruction Modified Available
Wave Three Eligibility Screening Script Form and Instruction Modified Available
Wave Two Eligibility Screening Script Form and Instruction Modified Available
Wave One Elligibility Screening Script Form and Instruction Modified Available
0 - SSB Pease Study 20190813 clean.docx Supporting Statement B Uploaded 2019-08-16 Available
0 - SSA Pease Study 20190815.docx Supporting Statement A Uploaded 2019-08-16 Available
0 - Pease Study Protocol 20190813 clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att24a_ATSDRPFASFactsheet.pdf Supplementary Document Uploaded 2019-08-15 Available
P_Att24_PFASResultsReport 20190813 clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att23_ClinicalTestResultsReport_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att22b_LetterRprtCriticalValue_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att22a_AdvncClinicalTestReportTrackingForm_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att22_AdvReportScriptClinicalTests_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att21_BodyBloodPressMsReport_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att14 PeaseManualofProcedures_rev110918x.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att11_ApptTrackingForm_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att09c_StudyFactSheet_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att09b_InformedConsentPacket_20190813 clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att09a_ApptReminderCard_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att08_RecrTrackingForm_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att07_WavesTwoThreeRecruitmentMaterials_20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att06_WaveOne_NHDHHSInvitationLttrsStudyRollout_20181218 clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att05_PeaseStudyCommnctnPlan_20190813 clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att04_JustificationSampleSizeCalcs 20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att03_BiochemAnalPlanChildrenAdults 20181109_clean.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att02_PFASLevelsPease_vs_ExtrnlPopn 20180802.docx Supplementary Document Uploaded 2019-08-15 Available
P_Att01_InvestigatorsKeyPersonnel updated 20180802.docx Supplementary Document Uploaded 2019-08-15 Available
AppndxF_Data Sharing and Disclosure Review 20190813.docx Supplementary Document Uploaded 2019-08-15 Available
AppndxE IRB Approval Memo 20180912.pdf Supplementary Document Uploaded 2019-08-15 Available
AppndxD PrivacyImpactAssessment 20181210.pdf Supplementary Document Uploaded 2019-08-15 Available
AppndxC_Pease_Feasibility_Assessment_November-2017_508.pdf Supplementary Document Uploaded 2019-08-15 Available
AppndxB1 ATSDR-2018-0008 SmmryCmntsRspnses 20190813.pdf Supplementary Document Uploaded 2019-08-15 Available
AppndxB Pease 60-day FRN.pdf Supplementary Document Uploaded 2018-12-20 Available
AppndxA Pease_Study_ Authorizing Legislation 20180802.pdf Supplementary Document Uploaded 2018-12-20 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
237378 Request for Medical Record Abstraction Instruction New
237377 Request for Child School Record Abstraction Instruction New
234702 Medical Record Abstraction - Child Form Modified
234701 Medical Record Abstraction - Adult Form Modified
234700 Child School Record Abstraction Form Modified
234699 Child Neurobehavioral Test Battery Instruction Modified
234698 Parent Neurobehavioral Test Battery Instruction Modified
234697 Child Questionnaire - Short Form Form Modified
234696 Child Questionnaire - Long Form Form Modified
234695 Adult Questionnaire Form Modified
234694 Blood Draw and Urine Collection Form Form Modified
234693 Body and Blood Pressure Measures Form Form Modified
234692 Medication List Form Modified
234691 Update Contact Information Hardcopy Form Form Modified
234690 Appointment Reminder Telephone Script Form and Instruction Modified
234689 Wave Three Eligibility Screening Script Form and Instruction Modified
234688 Wave Two Eligibility Screening Script Form and Instruction Modified
234687 Wave One Elligibility Screening Script Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2022 36 Months From Approved
5,852 0 0
1,454 0 0
42,227 0 0





table that charts list 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 5,852 0 0 5,852 0 0
Annual Time Burden (Hours) 1,454 0 0 1,454 0 0
Annual Cost Burden (Dollars) 42,227 0 0 42,227 0 0


Reginfo record details
  No