Household Eligibility Screener

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

OMB: 0923-0059

IC ID: 233850

Information Collection (IC) Details

View Information Collection (IC)

Household Eligibility Screener
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a Household Eligibility Screener PrtApndxA3_HHEligibilityScreener_06242020_clean2_.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances  76 FR 4432

1,345 0
   
Individuals or Households
 
   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

Title Document Date Uploaded
Household eligibility recruitment letter (Revised June 2020) PrtApndxA2_HHRecruitmentLetter_06242020_clean2_.docx 06/24/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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