Information Collection

Jasper and Newton Counties Missouri Lead Exposure Investigation

IC 254359 under ICR 202112-0923-002 · OMB 0923-0048.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0048 can be found here:

2025-06-23 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0048 Jasper and Newton Counties Missouri Lead Exposure Investigation	Form and Instruction
0923-0048 Participant Questionnaire P_AppxE1_JNC MO ATSDR Questionaire.docx	Form and Instruction
0923-0048 Biological Testing Tracking Form P_AppxE2_JNC MO ATSDR Biolgcl Testing Tracking Form.docx	Form and Instruction
0923-0048 Form 100 P_AppxI1_Form 100- Home Schematic.docx	Form
0923-0048 Form 110 P_AppxI2_Form 110 - Interior Environ Paint Assessment.docx	Form
0923-0048 Form 120 P_AppxI3_Form 120 - Ext Environ Paint Assessment.docx	Form
0923-0048 Form 200 P_AppxI4_Form 200 - Dust Wipe Collection.docx	Form
0923-0048 Form 300 P_AppxI5_Form 300 - Soil Composite Soil Collection.docx	Form
0923-0048 Form 400 P_AppxI6_Form 400 - Private Well Water Collection.docx	Form
0923-0048 Form 500 P_AppxI7_Form 500 - Public Tap Kitchen Tap Collection.docx	Form
Att1_JNC MO 0923-0048 GenIC SS-A_final.docx SSA	IC Document
Att2_JNC MO 0923-0048 GenIC SS-B.docx SSB	IC Document
0 - JNC MO 0923-0048 GenIC Submittal.docx GenIC Submittal Form	IC Document
Att3_JNC MO List of Attachments.docx List of Attachments	IC Document
Att4 Anaconda_Co_Smelter_HC-508.pdf EI Final Report Example	IC Document
Att5A_FctSht - Fight Lead Poisoning Healthy Foods.docx Factsheet - Fight Lead Poisoning Healthy Foods	IC Document
Att5B_FctSht - Protect Family from Lead in Home.docx Factsheet - Protect Family From Lead in Home	IC Document
Att5C_FctSht - Protect Family from Lead in Yard.docx Factsheet - Protect Family From Lead in Yard	IC Document
Att5D_FctSht - Safe Gardening Lead Soil.docx Safe Gardening Lead Soil	IC Document
Att5E_FctSht - Pregnancy and Lead - Stay Healthy During Pregnancy.docx Factsheet - Pregnancy and Lead	IC Document
Att6 0923-0048 PIA 20220209.pdf PIA	IC Document
Att7_ JNC MO EI Protocol.docx JNC Exposure Investigation Protocol	IC Document
Att8 Project Determination.pdf Project Determination	IC Document
P_AppxA- JNC MO Background 0923-0048.docx Background Info	IC Document
P_AppxC1_ JNC MO EI Fact Sheet.docx EI Fact Sheet	IC Document
P_AppxC2_JNC MO Newton County Recruitment Flyer.docx Newton County Recruitment Flyer	IC Document
P_AppxC3_JNC MO Jasper County Recruitment Flyer.docx Jasper County Recruitment Flyer	IC Document
P_AppxC4_JNC MO Social Media Recruitment Content.docx Social Media Recruitment Content	IC Document
P_AppxD1_JNC MO ATSDR PrivacyActStmt.docx Privacy Act Statement	IC Document
P_AppxD2_JNC MO ATSDR Adult Consent Form.docx ATSDR Adult Consent Form	IC Document
P_AppxD3_JNC MO ATSDR Parental Perm (eligible child).docx ATSDR Parental Permission	IC Document
P_AppxD4_JNC MO ATSDR Child Assent Form (minor non-participant).docx ATSDR Child Assent	IC Document
P_AppxD5_ JNC MO MDHHS Consent Form.docx MDHHS Consent Form	IC Document
P_AppxD6_ JNC MO EPA Consent Form.docx EPA Consent Form	IC Document
P_AppxF_ JNC MO Environmental Sampling Protocols 0923-0048.docx Environmental Sampling Protocols	IC Document
P_AppxG_ JNC EI Health and Safety Plan.docx EI Health and Safety Plan	IC Document
P_AppxH_ JNC MO Sample Results Letters 0923-0048.docx Sample Results Letters	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Jasper and Newton Counties Missouri Lead Exposure Investigation

Agency IC Tracking Number:

0923-0048-22GN

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0923-0048	Participant Questionnaire	P_AppxE1_JNC MO ATSDR Questionaire.docx	Yes	No	Fillable Fileable
Form and Instruction	0923-0048	Biological Testing Tracking Form	P_AppxE2_JNC MO ATSDR Biolgcl Testing Tracking Form.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 100	P_AppxI1_Form 100- Home Schematic.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 110	P_AppxI2_Form 110 - Interior Environ Paint Assessment.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 120	P_AppxI3_Form 120 - Ext Environ Paint Assessment.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 200	P_AppxI4_Form 200 - Dust Wipe Collection.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 300	P_AppxI5_Form 300 - Soil Composite Soil Collection.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 400	P_AppxI6_Form 400 - Private Well Water Collection.docx	Yes	No	Fillable Fileable
Form	0923-0048	Form 500	P_AppxI7_Form 500 - Public Tap Kitchen Tap Collection.docx	Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances

FR Citation: 83 FR 6591

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	426	426
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA	Att1_JNC MO 0923-0048 GenIC SS-A_final.docx	06/23/2022
SSB	Att2_JNC MO 0923-0048 GenIC SS-B.docx	06/23/2022
GenIC Submittal Form	0 - JNC MO 0923-0048 GenIC Submittal.docx	06/23/2022
List of Attachments	Att3_JNC MO List of Attachments.docx	06/23/2022
EI Final Report Example	Att4 Anaconda_Co_Smelter_HC-508.pdf	06/23/2022
Factsheet - Fight Lead Poisoning Healthy Foods	Att5A_FctSht - Fight Lead Poisoning Healthy Foods.docx	06/23/2022
Factsheet - Protect Family From Lead in Home	Att5B_FctSht - Protect Family from Lead in Home.docx	06/23/2022
Factsheet - Protect Family From Lead in Yard	Att5C_FctSht - Protect Family from Lead in Yard.docx	06/23/2022
Safe Gardening Lead Soil	Att5D_FctSht - Safe Gardening Lead Soil.docx	06/23/2022
Factsheet - Pregnancy and Lead	Att5E_FctSht - Pregnancy and Lead - Stay Healthy During Pregnancy.docx	06/23/2022
PIA	Att6 0923-0048 PIA 20220209.pdf	06/23/2022
JNC Exposure Investigation Protocol	Att7_ JNC MO EI Protocol.docx	06/23/2022
Project Determination	Att8 Project Determination.pdf	06/23/2022
Background Info	P_AppxA- JNC MO Background 0923-0048.docx	06/23/2022
EI Fact Sheet	P_AppxC1_ JNC MO EI Fact Sheet.docx	06/23/2022
Newton County Recruitment Flyer	P_AppxC2_JNC MO Newton County Recruitment Flyer.docx	06/23/2022
Jasper County Recruitment Flyer	P_AppxC3_JNC MO Jasper County Recruitment Flyer.docx	06/23/2022
Social Media Recruitment Content	P_AppxC4_JNC MO Social Media Recruitment Content.docx	06/23/2022
Privacy Act Statement	P_AppxD1_JNC MO ATSDR PrivacyActStmt.docx	06/23/2022
ATSDR Adult Consent Form	P_AppxD2_JNC MO ATSDR Adult Consent Form.docx	06/23/2022
ATSDR Parental Permission	P_AppxD3_JNC MO ATSDR Parental Perm (eligible child).docx	06/23/2022
ATSDR Child Assent	P_AppxD4_JNC MO ATSDR Child Assent Form (minor non-participant).docx	06/23/2022
MDHHS Consent Form	P_AppxD5_ JNC MO MDHHS Consent Form.docx	06/23/2022
EPA Consent Form	P_AppxD6_ JNC MO EPA Consent Form.docx	06/23/2022
Environmental Sampling Protocols	P_AppxF_ JNC MO Environmental Sampling Protocols 0923-0048.docx	06/23/2022
EI Health and Safety Plan	P_AppxG_ JNC EI Health and Safety Plan.docx	06/23/2022
Sample Results Letters	P_AppxH_ JNC MO Sample Results Letters 0923-0048.docx	06/23/2022

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