Information Collection

ATSDR Requests Form

IC 262208 under ICR 202309-0923-001 · OMB 0923-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ATSDR Requests Form	Form and Instruction
ATSDR Requests for Certified PHAs/HCs ATSDR Requests Form	Form and Instruction
ATSDR Requests for Certified PHAs/HCs Att4j ATSDR Requests Form (ARMSS) (NEW).pdf	Form and Instruction
ATSDR Requests for Certified PHAs/HCs Att4j ATSDR Requests Form (ARMSS) (NEW).pdf	Form and Instruction

IC Title:

ATSDR Requests Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	ATSDR Requests for Certified PHAs/HCs	Att4j ATSDR Requests Form (ARMSS) (NEW).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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