PAsS Data Submission Form

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx

ROUND 18
Please complete and return this form by Friday December 4, 2020

LABORATORY ID: P-002
Run/Species
Run 1

P-2020-04

P-2020-05

P-2020-06

AB
AC
As(III)
As(V)
DMA
MMA
TMAO

Run 2
AB
AC
As(III)
As(V)
DMA
MMA
TMAO
AB – arsenobetaine; AC – arsenocholine; As(III) – arsenous acid;
DMA – dimethylarsinate; As(V) – arsenate;
MMA – monomethylarsonate; TMAO – trimethylarsine oxide
PLEASE provide the LOD values for each species if measurement is below LOD.
Note: Enter results in concentration units in terms of weight of As measured (µg As/L) for
each species, not the formula concentration (µg molecule/ L). If necessary, please convert
your results by multiplying each by the atomic weight of arsenic divided by the formula
weight of the species:
74 . 98

Species concentration (µg/L) X species formula weight

If you have any questions or comments, please contact us by email at: [email protected]
Fax: (770) 488-4097
CDC 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 (0920-xxxx).