Information Collection

EJScreen 2022 Impact Survey

IC 246181 under ICR 202012-2010-001 · OMB 2010-0042.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5800-016 EJScreen 2022 Impact Survey	Form
5800-016 EJScreen 2022 Impact Survey 2022 EJSCREEN Survey (12-16-20).docx	Form
5800-016 EJScreen 2022 Impact Survey 2022 EJSCREEN Survey (12-16-20).docx	Form
EJSCREEN Survey Justification (12-15-20).docx Justification	IC Document
EJSCREEN Survey Justification (12-15-20).docx Justification	IC Document

IC Title:

Agency IC Tracking Number:

2434.126

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5800-016	EJScreen 2022 Impact Survey	2022 EJSCREEN Survey (12-16-20).docx		Yes	Yes	Fillable Fileable

Line of Business: Environmental Management

Subfunction: Pollution Prevention and Control

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification	EJSCREEN Survey Justification (12-15-20).docx	03/10/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.