Medical Record Abstraction - Adult

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⚠️ Notice: This information collection may be referencing outdated material.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
Medical Record Abstraction - Adult Form
Medical Record Abstraction -Adult P_Att19a_MedRecAbstrctnForm_Adult_20180802.docx Form

Information Collection (IC) Details

IC Title:	Medical Record Abstraction - Adult	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	Medical Record Abstraction -Adult	P_Att19a_MedRecAbstrctnForm_Adult_20180802.docx		Yes	No	Paper Only

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: 25	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	375	375
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	2,645	2,645

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.