Adult Questionnaire

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⚠️ Notice: This information collection may be referencing outdated material.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
Adult Questionnaire Form and Instruction
Adult questionnaire M_Att16_AdltQstnnr_20200714 clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Adult 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 and Instruction	none	Adult questionnaire	M_Att16_AdltQstnnr_20200714 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09–19–0001, ‘‘Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"	FR Citation: 76 FR 4432

Number of Respondents: 2,333	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	2,333	2,333
Annual IC Time Burden (Hours)	1,167	1,167
Annual IC Cost Burden (Dollars)	29,139	29,139

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.