ATSDR Site Impact Assessment Form

[ATSDR] APPLETREE Performance Measures

Att4c1 ATSDR SIA Form (WORD) 08212023

ATSDR Site Impact Assessment Form

OMB: 0923-0057

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ATSDR Site Impact Assessment Form (ARMSS Word Text)

Form Approved

OMB No. 0923-0057

Exp. Date 09/30/2023


ATSDR estimates the average public reporting burden for this collection of information as 7 minutes 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 current 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).



Site Impact Information

Type of document

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Certified or Non-Certified

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Document Title

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Document Release Date

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Lead Health Assessor

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Lead Health Educator

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Agency Activities and Document Conclusions

Other Information about this site

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Who we worked with at this site

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Number of people assessed

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Number of people potentially exposed to contaminants at levels of health concern

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Number of people currently exposed to contaminants at levels of health concern

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Primary contaminant assessed at the site

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Other contaminants

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What Pathways were evaluated at the site

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Was enough data available to make a health call

Yes/No



For ATSDR Use Only

QC Complete

Yes/No

Choose Reviewer for this form

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCrum, Kendall (ATSDR/OAD/OCDAPS)
File Modified0000-00-00
File Created2023-09-20

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