Information Collection

Appx C_ Adult Follow-up Survey Online

IC 251054 under ICR 202212-0923-001 · OMB 0923-0064.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0064 Appx C_ Adult Follow-up Survey Online	Form and Instruction
Form 0923-0064 Evaluating the Association between Serum Concentrations of Per- and Polyfluoroalkyl Substances (PFAS) and Symptoms and Diagnoses of Selected Acute Viral Illnesses Adult (≥ 18 years of age) Follow-up Appx C_ Adult Follow-up Survey Online	Form and Instruction
0923-0064 Evaluating the Association between Serum Concentrations P_ApndxC1_F-UAdltSrvy_REDCap.pdf	Form and Instruction
0923-0064 Evaluating the Association between Serum Concentrations P_ApndxC1_F-UAdltSrvy_REDCap.pdf	Form and Instruction
P_ApndxC_F-UAdltSrvy (Word)_20221213.docx Follow-up AdultSurvey (Word)	IC Document
P_ApndxC_F-UAdltSrvy (Word)_20221213.docx Follow-up AdultSurvey (Word)	IC Document

IC Title:

Agency IC Tracking Number:

0923-0064-23BK

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0923-0064	Evaluating the Association between Serum Concentrations of Per- and Polyfluoroalkyl Substances (PFAS) and Symptoms and Diagnoses of Selected Acute Viral Illnesses Adult (â¥ 18 years of age) Follow-up	P_ApndxC1_F-UAdltSrvy_REDCap.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (retrievable by name or SSN)

FR Citation: 76 FR 4431

Number of Respondents: 1,050

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,200	4,200
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Follow-up AdultSurvey (Word)	P_ApndxC_F-UAdltSrvy (Word)_20221213.docx	12/14/2022

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