ATSDR Recommendation Follow-up Form

APPLETREE Performance Measures

Att4i Rec Follow-up Form 20200325.xlsm

ATSDR Recommendation Follow-up

OMB: 0923-0057

Document [xlsx]
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Overview

Follow-up
Options


Sheet 1: Follow-up

Attachment 4i. ATSDR Recommendation Follow-up Form




ATSDR Recommendation Follow-Up Form



ATSDR estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).



Basic site information
Site name:

Zip code:

Were recommendations provided for this site?
(If yes, complete entire form. If no, end here.)


Recommendation #1
Description of recommendation (1-2 sentence max):

Select the recommendation category:

Potential health concern address (1 sentence max):

Recommendation status:

Impact on exposure:

Date recommendation was adopted, if applicable:

Status update on recommendation if not yet implemented:

Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)


Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)


Description of actions taken to follow-up on recommendations:

Recommendation #2
Description of recommendation (1-2 sentence max):

Select the recommendation category:

Potential health concern address (1 sentence max):

Recommendation status:

Impact on exposure:

Date recommendation was adopted, if applicable:

Status update on recommendation if not yet implemented:

Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)


Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)


Description of actions taken to follow-up on recommendations:

Recommendation #3
Description of recommendation (1-2 sentence max):

Select the recommendation category:

Potential health concern address (1 sentence max):

Recommendation status:

Impact on exposure:

Date recommendation was adopted, if applicable:

Status update on recommendation if not yet implemented:

Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)


Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)


Description of actions taken to follow-up on recommendations:

Recommendation #4
Description of recommendation (1-2 sentence max):

Select the recommendation category:

Potential health concern address (1 sentence max):

Recommendation status:

Impact on exposure:

Date recommendation was adopted, if applicable:

Status update on recommendation if not yet implemented:

Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)


Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)


Description of actions taken to follow-up on recommendations:

If more than four recommendations were provided for this document, copy lines 23-27 and columns A-B and paste below as needed.


Sheet 2: Options

Yes
Impose institutional or regulatory controls to eliminte/reduce/limit exposure


Non-verifiable Describes a recommendation to an individual community member that cannot be verified and is therefore acceptabley deemed non-verifiable
No
Evacuate/relocate exposed population


Pending acceptance Describes a recommendation that has been provided to a stakeholder, but has not yet been accepted by that stakeholder. Acceptance is defined as agreeing with the recommendation and committing to implement the recommendation in the future, but not yet having implemented the recommendation.


Conduct exposure Investigation


Accepted Describes a recommendation that has been provided to a stakeholder, and that stakeholder accepts the recommendation and commits to implement it in the future, but has not yet implemented it.


Conduct ATSDR health study


Implemented Describes a recommendation that has been fully implemented to reduce or remove the hazardous environmental exposure to the full extent recommended.


State-funded health study


Rejected Describes a recommendation that was rejected and not accepted or implemented by the stakeholder


Conduct/continue monitoring


Eliminated Describes a recommendation that was eliminated by the health assessment due to lack of application at a follow-up date.


Other site source/media/contamination characterization






ATSDR health education activity


For the purposes of recommendations, a stakeholder will be described as any entity for which a recommendation can reasonably be tracked and would impact >1 person, such as a regulatory authority, a business owner, a local or state decision-maker, etc.


State-led health education activity






Remediation (e.g. site clean up) to eliminate/reduce hazards






Restrict use of source of hazards


















Reduction


Community leader


Total Elimination


Community advocacy group


Unknown


Federal regulatory agency






State regulatory agency






Local regulatory agency






Other regulatory agency






Industry/Business























OS comment: Unclear how this tab is to be used. Can you provide text instructions above the fields?






APPLETREE comment: This tab displays the options for the drop-downs in the form. It will be a hidden tab when the form is used.



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