Water Information Collection Form for Environmental Prot

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study

M_Att3d_WaterInfoCollec_EnvironPrtctnAgencies_CLEAN

Drinking Water Information Collection (Environmental Protection Agencies)

OMB: 0923-0063

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Attachment 3d.


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Form Approved

OMB No. 0923-00xx

Exp. Date xx/xx/20xx

Multi-site Study

Eligibility Screening Script

Flesch-Kincaid Readability Score – 5.8

Drinking Water Information Collection Form for Environmental Protection Agencies



  1. Is the site served by a public water supply?

If yes, the following information will be requested from the water purveyor:

  • List of residences served by the water purveyor

    • Name of person and street address

  • Distribution system characteristics

    • Specifically, whether the PFAS concentrations can be assumed to be relatively uniform throughout the system or whether the system had specific areas with substantially higher or lower PFAS concentrations.

    • Sources of drinking water (e.g., supply wells, reservoir)

    • Any interconnections between water systems; if so, then frequency of use of the interconnection and the amount of water supplied by the interconnection when in use

  • If distribution system characteristics indicate supply wells, the following information will be requested

    • Historical and current supply well information

      • Monthly/Daily production logs

      • Dates of operation

  • Results from all relevant PFAS sampling



If no, please proceed to question 2.

  1. Does the site have contaminated private wells?

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ATSDR estimates the average public reporting burden for this collection of information as 7 hours 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-xxxx).

If yes, the following information will be requested from state and/or local health and environmental agencies:

  • List of residences with a contaminated private well

    • Name of person and street address

  • Results from all relevant PFAS sampling of private wells

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AuthorCDC User
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