Information Collection

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire

IC 245365 under ICR 202003-0920-005 · OMB 0920-1173.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1173 Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Form and Instruction
0920-1173 Invitation Letter and Response Form AttB_Invitation Letter Response Form_20201120.docx	Form and Instruction
0920-1173 Screening Survey AttC_Screening Survey_20201120.docx	Form and Instruction
0920-1173 Food Log AttE_Food Log_20201120.docx	Form and Instruction
0920-1173 Urine Collection Directions and Water Collection Log AttF_Urine Collctn Directns Water Collctn Log_20201120.docx	Form and Instruction
0920-1173 Survey AttG_Survey_20201120.docx	Form and Instruction
1 - SSA_Exp to As U Prvt Well Water_20201120.docx Supporting Statement A	IC Document
1 - SSB_Exp to As U Prvt Well Water_20201120.docx Supporting Statement B	IC Document
0 - Request to use Generic Clearance Form_ 20201120.docx GenIC Request Form	IC Document
AttD_Consent Form_20201120.docx Consent Form	IC Document
AttA_Letters of Collaboration.pdf Letters of Collaboration	IC Document
AttH_Participant Results Letter_20201120.docx Participant Reuslts Letter	IC Document
AttI_STARS Determination Form.pdf Non-Research Determination	IC Document
SSA CLN 20210308_updated.docx Revised Supporting Statement A	IC Document

IC Title:

Agency IC Tracking Number:

0920-1173-21BM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	0920-1173	Invitation Letter and Response Form	AttB_Invitation Letter Response Form_20201120.docx	NA	No	Paper Only
Form and Instruction	0920-1173	Screening Survey	AttC_Screening Survey_20201120.docx	NA	No	Paper Only
Form and Instruction	0920-1173	Food Log	AttE_Food Log_20201120.docx	NA	No	Paper Only
Form and Instruction	0920-1173	Urine Collection Directions and Water Collection Log	AttF_Urine Collctn Directns Water Collctn Log_20201120.docx	NA	No	Paper Only
Form and Instruction	0920-1173	Survey	AttG_Survey_20201120.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 1,650

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,310	2,310
Annual IC Time Burden (Hours)	544	544
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	1 - SSA_Exp to As U Prvt Well Water_20201120.docx	01/15/2021
Supporting Statement B	1 - SSB_Exp to As U Prvt Well Water_20201120.docx	01/15/2021
GenIC Request Form	0 - Request to use Generic Clearance Form_ 20201120.docx	01/15/2021
Consent Form	AttD_Consent Form_20201120.docx	01/15/2021
Letters of Collaboration	AttA_Letters of Collaboration.pdf	01/15/2021
Participant Reuslts Letter	AttH_Participant Results Letter_20201120.docx	01/15/2021
Non-Research Determination	AttI_STARS Determination Form.pdf	01/15/2021
Revised Supporting Statement A	SSA CLN 20210308_updated.docx	03/09/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.