2616.02 Appendix A - Example Survey Instrument

Appendix A – Data Collection Instrument

ICR Control Number: 2616.02

EPA ICR Number: 2040-NEW

Expiration Date: December 31, 2023

Burden Statement: There were 2,181 medium community water systems, 708 large systems and 35 NFPNCWs serving 10,000 or more people in the 2021 DWINSA sample. Across these system categories there is no substantive difference in the process or data collection instrument being used for the one-time LSL update and it is assumed that burden will be the same across these categories. EPA will conduct data collection for the 606 small CWSs serving 3,300 and fewer persons and 99 NFPNCWs serving fewer than 10,000 persons. It is assumed that since these systems generally have fewer lines that the burden will be slightly less than for medium and large systems. EPA will email the surveys to the small systems.

The following pages present the state data collection instrument.