Medical Record Abstraction - Adult

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⚠️ Notice: This information collection may be referencing outdated material.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
Medical Record Abstraction - Adult Form and Instruction
Multi-site Study Medical Record Abstraction Form - Adult M_Att17a_MedRecAbstrctnForm_Adult_20191212.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Medical Record Abstraction - Adult	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	n/a	Multi-site Study Medical Record Abstraction Form - Adult	M_Att17a_MedRecAbstrctnForm_Adult_20191212.docx		No		Paper Only

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: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	16,927	16,927

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.