Environmental Sample Collection Form

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0059 can be found here:

Documents and Forms

Document Name Document Type
Environmental Sample Collection Form Form
Environmental sample collection form PrtApndxC2_EnvSampleCollctnFrm_20200205 clean.docx Form

Information Collection (IC) Details

IC Title:	Environmental Sample Collection Form	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	Environmental sample collection form	PrtApndxC2_EnvSampleCollctnFrm_20200205 clean.docx		Yes	Yes	Fillable Fileable

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: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	457	457

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.