Request for Medical Record Abstraction

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

Documents and Forms

Document Name Document Type
P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx Instruction
P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx Instruction

Information Collection (IC) Details

IC Title:	Request for Medical Record Abstraction	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
Instruction			P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx		Yes	No	Paper Only

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: 10	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	550	550
Annual IC Time Burden (Hours)	183	183
Annual IC Cost Burden (Dollars)	10,024	10,024

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.