ATSDR Technical Assistance (TA) Activity Form

ATSDR Technical Assistance TA (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 4 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).

Create Activity Form (Screen 1)

Activity Type	Dropdown
Requested Source	Dropdown
Requested Source Details (Optional)	Fill in
Request Description	Fill in
Source POC (Optional)	Fill in
Coop Program	Yes/No
Jurisdiction	Dropdown
Choose Safe Places for Early Care and Education	Yes/No
Activity Name	Fill in
Section	Dropdown
Team/Region	Dropdown
Current POC	Dropdown
Planned Start Date	Select date
Notes (Optional)	Fill in

Edit Technical Assist

Description	Upload document
Technical Assist details
Actual Start Date	Select Date
Complete Date	Select Date
Health Assessor	Dropdown
Response Summary	Fill in

Approval Information (for ATSDR Use Only)

Reviewer	Dropdown
TA Approved for Release	Yes/No