Household Eligibility Screener

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⚠️ Notice: This information collection may be referencing outdated material.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
Household Eligibility Screener Form and Instruction
Household Eligibility Screener PrtApndxA3_HHEligibilityScreener_06242020_clean2_.docx Form and Instruction
PrtApndxA2_HHRecruitmentLetter_06242020_clean2_.docx Household eligibility recruitment letter (Revised June 2020) IC Document

Information Collection (IC) Details

IC Title:	Household Eligibility Screener	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 and Instruction	n/a	Household Eligibility Screener	PrtApndxA3_HHEligibilityScreener_06242020_clean2_.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: 1,345	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	1,345	1,345
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	2,730	2,730

Documents for IC

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.