Adult Questionnaire

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0061 can be found here:

Documents and Forms

Document Name Document Type
Adult Questionnaire Form
Adult Questionnaire P_Att18_PeaseAdltQstnnr_20190813 clean.docx Form

Information Collection (IC) Details

IC Title:	Adult Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	none	Adult Questionnaire	P_Att18_PeaseAdltQstnnr_20190813 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: 367	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	367	367
Annual IC Time Burden (Hours)	184	184
Annual IC Cost Burden (Dollars)	4,584	4,584

Documents for IC

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.