Eligibility Screening

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0063 can be found here:

Documents and Forms

Document Name Document Type
Eligibility Screening Form and Instruction
Eligibility screener M_Att04 ElgbltyScrng_20201027Cln.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screening	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	none	Eligibility screener	M_Att04 ElgbltyScrng_20201027Cln.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: 7,982	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	7,982	7,982
Annual IC Time Burden (Hours)	1,330	1,330
Annual IC Cost Burden (Dollars)	33,231	33,231

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.