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Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire 0920-1173-21BM
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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

Health Illness Prevention

09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

1,650 0
   
Individuals or Households
 
   0 %

  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 2,310 0 2,310 0 0 0
Annual IC Time Burden (Hours) 544 0 544 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.