Att4c1 ATSDR SIA Form (WORD) 08212023

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	Dropdown
Certified or Non-Certified	Dropdown
Document Title	Fill in
Document Release Date	Select Date
Lead Health Assessor	Dropdown
Lead Health Educator	Fill in

Agency Activities and Document Conclusions

Other Information about this site	Check box (Select all that apply)
Who we worked with at this site	Check box (Select all that apply)
Number of people assessed	Fill in
Number of people potentially exposed to contaminants at levels of health concern	Fill in
Number of people currently exposed to contaminants at levels of health concern	Fill in
Primary contaminant assessed at the site	Dropdown
Other contaminants	Fill in
What Pathways were evaluated at the site	Check box (Select all that apply)
Was enough data available to make a health call	Yes/No

For ATSDR Use Only

QC Complete	Yes/No
Choose Reviewer for this form	Dropdown