Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
EA Participants (All Ages) - Biological Testing Tracking	Form	Unchanged	Available
Environmental Sample Collection Form	Form	Unchanged	Available
Environmental Sampling Consent	Form	Unchanged	Available
Household Recruitment Script for Environmental Sampling	Form	Unchanged	Available
Exposure Questionnaire for Biological Testing - Child Completed	Form	Unchanged	Available
Child Assent	Form and Instruction	Unchanged	Available
Exposure Questionnaire for Biological Testing - Parent Proxy	Form	Unchanged	Available
Parental Permission	Form	Unchanged	Available
Adult Exposure Assessment Questionnaire	Form	Unchanged	Available
Adult Consent	Form	Unchanged	Available
Household Eligibility Screener	Form	Unchanged	Available
Community Event Evaluation Survey	Form	Unchanged	Available
0923-0059 Change Request Justification and crosswalk table_PFAS EA comm materials 20200109.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-01-30	Available
0923-0059 PFAS EA Factsheet - Understanding Your PFAS Test Results 20200109 trackchanges.docx	Supplementary Document	Uploaded 2020-01-10	Available
0923-0059 PFAS EA Factsheet - Understanding Your PFAS Test Results 20200109 clean.docx	Supplementary Document	Uploaded 2020-01-10	Available
0923-0059 PFAS - Overview Sci Guidance for Clinicians 20200109 track changes.docx	Supplementary Document	Uploaded 2020-01-10	Available
0923-0059 PFAS - Overview Sci Guidance for Clinicians 20200109 clean.docx	Supplementary Document	Uploaded 2020-01-10	Available
PrtApndxG2_RsultsLttrEnviroSmpling 20200109 track changes.docx	Supplementary Document	Uploaded 2020-01-10	Available
PrtApndxG2_RsultsLttrEnviroSmpling 20200109 clean.docx	Supplementary Document	Uploaded 2020-01-10	Available
PrtApndxG1_RsultsLttrBiolgcSmplng 20200109 track changes.docx	Supplementary Document	Uploaded 2020-01-10	Available
PrtApndxG1_RsultsLttrBiolgcSmplng 20200109 clean.docx	Supplementary Document	Uploaded 2020-01-10	Available
0923-0059 Change Request Justification and crosswalk table_PFAS EA comm materials 20200109.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-01-10	Available
0923-0059 Change Request Justification and crosswalk table PrtApndxB4 20190718.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-07-29	Available
Site Selection Supplement_20190509.docx	Supplementary Document	Uploaded 2019-06-27	Available
PFAS Exposure Assessment Protocol_20190604_clean.docx	Supplementary Document	Uploaded 2019-06-27	Available
PFAS EA SSB_20190501_clean.docx	Supporting Statement B	Uploaded 2019-06-27	Available
PFAS EA SSA_20190524 clean.docx	Supporting Statement A	Uploaded 2019-06-27	Available
PrtApndxE_UrineCollctnInstrctns 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxD_ChainCustodyForms 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxI_DataMangmntPlan 20181012.docx	Supplementary Document	Uploaded 2019-06-27	Available
PrtApndxH_SiteHlthSafetyPlan 20181024.docx	Supplementary Document	Uploaded 2019-06-27	Available
Att6 PFAS EA Research Determination 20180711.pdf	Supplementary Document	Uploaded 2018-11-01	Available
Att5 PIA_PFAS EA signed OCISO 20181001.pdf	Supplementary Document	Uploaded 2018-11-01	Available
Att4 ExmpleEIRprt for PFAS 20161128.pdf	Supplementary Document	Uploaded 2019-06-27	Available
Att3 PFAS Exposure Assessment Technical Tools (PEATT).pdf	Supplementary Document	Uploaded 2019-06-27	Available
Att2a Agency Responses to Public Comments 20181012.pdf	Supplementary Document	Uploaded 2018-11-01	Available
Att2 PFAS EA 60-day FRN 20180719.pdf	Supplementary Document	Uploaded 2018-11-01	Available
Att1 PFAS EA Authorizing Legislation 20181012.pdf	Supplementary Document	Uploaded 2018-11-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
236722	EA Participants (All Ages) - Biological Testing Tracking	Form	Unchanged
233861	Environmental Sample Collection Form	Form	Unchanged
233860	Environmental Sampling Consent	Form	Unchanged
233859	Household Recruitment Script for Environmental Sampling	Form	Unchanged
233858	Exposure Questionnaire for Biological Testing - Child Completed	Form	Unchanged
233857	Child Assent	Form and Instruction	Unchanged
233855	Exposure Questionnaire for Biological Testing - Parent Proxy	Form	Unchanged
233853	Parental Permission	Form	Unchanged
233852	Adult Exposure Assessment Questionnaire	Form	Unchanged
233851	Adult Consent	Form	Unchanged
233850	Household Eligibility Screener	Form	Unchanged
233849	Community Event Evaluation Survey	Form	Unchanged

ICR Details

OMB Control No: 0923-0059	ICR Reference No: 202001-0923-003
Status: Historical Inactive	Previous ICR Reference No: 201907-0923-001
Agency/Subagency: HHS/TSDR	Agency Tracking No: 0923-0059-20FT
Title: Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 01/30/2020
	Date Received in OIRA: 01/10/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	06/30/2022	06/30/2022
Responses	8,551	0	8,551
Time Burden (Hours)	2,131	0	2,131
Cost Burden (Dollars)	33,029	0	33,029

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Abstract: This information collection addresses the requirements for completing exposure assessments (EAs) for PFAS authorized in Section 8006 of the Consolidated Appropriations Act, 2018. ATSDR/NCEH will use statistical methods to recruit respondents at a minimum of eight current or former domestic military installations known to have PFAS contamination in water sources. ATSDR will collect biological and environmental samples to evaluate exposure. The need for a change request was initiated by OMB requesting a few changes that were made to several documents.

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Authorizing Statute(s): PL: Pub.L. 115 - 141 8006 Name of Law: Consolidated Appropriations Act
   US Code: 42 USC 9604 Name of Law: CERCLA
   US Code: 42 USC 301 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 34135	07/19/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 60867	11/27/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Household Eligibility Screener	NA	Household Eligibility Screener
Community Event Evaluation Survey	NA	PFAS Exposure Assessment Community Event Evaluation
Adult Consent	NA	Adult Consent
Adult Exposure Assessment Questionnaire	NA	Adult Exposure Assessment
Parental Permission	NA	Parental Permission Form
Exposure Questionnaire for Biological Testing - Parent Proxy	NA	Exposure Assessment Child
Child Assent	none	Assent for Minors
Exposure Questionnaire for Biological Testing - Child Completed	NA	Exposure Assessment Child
Household Recruitment Script for Environmental Sampling	NA	Household Recruitment Script for Environmental Sampling
Environmental Sampling Consent	NA	Consent for Environmental Sampling
Environmental Sample Collection Form	NA	Environmental Sampling Collection Form
EA Participants (All Ages) - Biological Testing Tracking	NA	FAS EA Biological Testing Tracking Form

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $3,500,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/10/2020

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