0923-0048 Form 200

Appendix I4.

Form Approved

OMB No. 0923-0048 Exp. Date 06/30/2022

FORM 200

ATSDR estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

Dust Wipe Collection

___________________________		___________________________
Place ID Sticker Here		Inspector and Date
Room	Floor Sample		Window Sample
Entryway	☐ Carpet ☐ Hard Surface Dimension (inches) __________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-E-1		NA
Primary Living Area	☐ Carpet ☐ Hard Surface Dimension (inches) __________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-L-F-1		Dimension (inches) ________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-L-W-1
Kitchen	☐ Carpet ☐ Hard Surface Dimension (inches) __________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-K-F-1		Dimension (inches) ________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-K-W-1
Child’s Bedroom	☐ Carpet ☐ Hard Surface Dimension (inches) __________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-CB-F-1		Dimension (inches) ________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-CB-W-1

Child’s Play Area

☐ Carpet ☐ Hard Surface Dimension (inches) __________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-PA-F-1

Dimension (inches) ________ Visible Soil/Dust: ☐ Y ☐ N Vis. Paint Chips: ☐ Y ☐ N Comments: Sample Number: D-PA-W-1