Adult Exposure Assessment Questionnaire

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⚠️ Notice: This information collection may be referencing outdated material.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
Adult Exposure Assessment Questionnaire Form
Adult-Child Exposure Assessment Questionnaire PrtApndxF1_PFAS EAs Adult Child ExpAssmntQstnnre_20200205 clean.docx Form

Information Collection (IC) Details

IC Title:	Adult Exposure Assessment Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	none	Adult-Child Exposure Assessment Questionnaire	PrtApndxF1_PFAS EAs Adult Child ExpAssmntQstnnre_20200205 clean.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: 1,501	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	1,501	1,501
Annual IC Time Burden (Hours)	751	751
Annual IC Cost Burden (Dollars)	18,267	18,267

Documents for IC

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.