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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.