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Household Eligibility Screener
Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)
OMB: 0923-0059
IC ID: 233850
OMB.report
HHS/TSDR
OMB 0923-0059
ICR 202002-0923-001
IC 233850
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0059 can be found here:
2022-06-17 - Revision of a currently approved collection
2020-06-18 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Household Eligibility Screener
Form
Household eligibility screener
PrtApndxA3_HHEligibilityScreener_20200205 clean.docx
Form
PrtApndxA2_HHRecruitmentLetter_20200205 clean.docx
Household eligibility recruitment letter
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Household Eligibility Screener
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
Household eligibility screener
PrtApndxA3_HHEligibilityScreener_20200205 clean.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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:
1,345
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,345
0
0
0
0
1,345
Annual IC Time Burden (Hours)
112
0
0
0
0
112
Annual IC Cost Burden (Dollars)
2,730
0
0
0
0
2,730
Documents for IC
Title
Document
Date Uploaded
Household eligibility recruitment letter
PrtApndxA2_HHRecruitmentLetter_20200205 clean.docx
02/13/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.