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 201909-0923-001 · OMB 0923-0061 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Medical Record Abstraction - Child Form Unchanged Available
Medical Record Abstraction - Adult Form Unchanged Available
Child School Record Abstraction Form Unchanged Available
Child Questionnaire - Short Form Form Unchanged Repair queued
Child Questionnaire - Long Form Form Unchanged Available
Adult Questionnaire Form Unchanged Available
Blood Draw and Urine Collection Form Form Unchanged Available
Body and Blood Pressure Measures Form Form Unchanged Repair queued
Medication List Form Unchanged Repair queued
Update Contact Information Hardcopy Form Form Unchanged Available
Appointment Reminder Telephone Script Form and Instruction Unchanged Available
Wave Three Eligibility Screening Script Form and Instruction Unchanged Available
Wave Two Eligibility Screening Script Form and Instruction Unchanged Available
Wave One Elligibility Screening Script Form and Instruction Unchanged Available
P_Att09b_InformedConsentPacket_20190823 clean.docx Supplementary Document Uploaded 2019-09-05 Available
Pease Study Protocol 20190823 clean.docx Supplementary Document Uploaded 2019-09-05 Available
1 - AppndxE IRB Apprvl Memos 20190903.pdf Supplementary Document Uploaded 2019-09-05 Available
0923-0061 Change Request Justification 20190903.docx Justification for No Material/Nonsubstantive Change Uploaded 2019-09-05 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 Repair queued
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 Repair queued
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 Repair queued

IC Document Collections

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

ICR Details

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





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


Reginfo record details
  No