Information Collection

ATSDR Site Impact Assessment Form

IC 226336 under ICR 202004-0923-001 · OMB 0923-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ATSDR Site Impact Assessment Form	Form and Instruction
Att4c SIA Form_Word 20200325.docx	Other-Word document to display instr
Site Impact Assessment Form Att4c SIA Form_Screenshots 20200325.docx	Form and Instruction

IC Title:

ATSDR Site Impact Assessment Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Site Impact Assessment Form	Att4c SIA Form_Screenshots 20200325.docx		Yes	Yes	Fillable Fileable
Other-Word document to display instrument content			Att4c SIA Form_Word 20200325.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	112	-38	150
Annual IC Time Burden (Hours)	13	-5	18
Annual IC Cost Burden (Dollars)	487	487	0

Documents for IC

table that charts IC Documents
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.