Environmental sample collection form

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

PrtApndxC2_EnvSampleCollctnFrm_20220609

OMB: 0923-0059

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Appendix C2: Environmental Sample Collection Form



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Form Approved

OMB No. 0923-0059

Exp. Date 06/30/2022



Environmental Sample Collection Form

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ATSDR estimates the average public reporting burden for this collection of information as 15 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 (0923-0059).



EA ID: ______________________________________________________

Date and time of Sample Collection: ______________________________________

Address of Sample Collection: ___________________________________

Notes:



Shape3 Samples Collected:

Tap Water – Sample ID ________________________________________________________

Tap Water Sample Location Description ___________________________________________

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Tap Water 2 – Sample ID ________________________________________________________

Shape5 Tap Water 2 Sample Location Description ___________________________________________

Shape6 Tap Water Blank – Sample ID ___________________________________________________

Indoor Dust – Sample ID _______________________________________________________

Shape7 Indoor Dust Sample Location Description __________________________________________

Indoor Dust Blank – Sample ID __________________________________________________



Data Collection Technician: ____________________________ ________________________________

Printed Name Signature

Shape8 Location of Samples Inside the Home:





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKaren Scruton
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File Created2023-08-20

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