Information Collection

EJScreen 2022 Impact Survey

IC 246181 under ICR 202106-2030-001 · OMB 2030-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2030-0051 can be found here:

Documents and Forms

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
EJSCREEN Survey Justification (12-15-20).docx Justification IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EJScreen 2022 Impact Survey	Agency IC Tracking Number:	2434.126

IC Status: New

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	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 %

	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

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.