Information Collection Request
ICR 201909-0923-001 · OMB 0923-0061 · Public filing
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0923-0061 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 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 | Unchanged | Available |
| Body and Blood Pressure Measures |
Form | Unchanged | Repair queued |
| Medication List |
Form | Unchanged | Repair queued |
| Update Contact Hardcopy Form |
Form | Unchanged | Available |
| Appointment Reminder Telephone Script |
Form and Instruction | Unchanged | Available |
| Wave Three Eligibility Script |
Form and Instruction | Unchanged | Available |
| Wave Two Eligibility Script |
Form and Instruction | Unchanged | Available |
| Wave One Eligibility 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
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 237378 |  Request for Medical Record Abstraction |
Instruction | Unchanged | |
| 237377 | Request for Child School Record Abstraction |
Instruction | Unchanged | |
| 234702 | Medical Record Abstraction - Child |
Form | Unchanged | Medical Record Abstraction - Child |
| 234701 | Medical Record Abstraction - Adult |
Form | Unchanged | Medical Record Abstraction -Adult |
| 234700 | Child School Record Abstraction |
Form | Unchanged | Child School Record Abstraction |
| 234699 | Child Neurobehavioral Test Battery |
Instruction | Unchanged | |
| 234698 | Parent Neurobehavioral Test Battery |
Instruction | Unchanged | |
| 234697 | Child Questionnaire - Short Form |
Form | Unchanged | Child Questionnaire - Short Form |
| 234696 | Child Questionnaire - Long Form |
Form | Unchanged | Child Questionnaire - Long Form |
| 234695 | Adult Questionnaire |
Form | Unchanged | Adult Questionnaire |
| 234694 | Blood Draw and Urine Collection Form |
Form | Unchanged | Blood Draw and Urine Collection |
| 234693 | Body and Blood Pressure Measures Form |
Form | Unchanged | Body and Blood Pressure Measures |
| 234692 | Medication List |
Form | Unchanged | Medication List |
| 234691 | Update Contact Information Hardcopy Form |
Form | Unchanged | Update Contact Hardcopy Form |
| 234690 | Appointment Reminder Telephone Script |
Form and Instruction | Unchanged | Appointment Reminder Telephone Script |
| 234689 | Wave Three Eligibility Screening Script |
Form and Instruction | Unchanged | Wave Three Eligibility Script |
| 234688 | Wave Two Eligibility Screening Script |
Form and Instruction | Unchanged | Wave Two Eligibility Script |
| 234687 | Wave One Elligibility Screening Script |
Form and Instruction | Unchanged | Wave One Eligibility Screening Script |
ICR Details
| OMB Control No | 0923-0061 |
|---|