ATSDR Recommendation Follow-up Form

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Attachment 4i. ATSDR Recommendation Follow-up Form
ATSDR Recommendation Follow-Up Form

Form Approved
OMB No. 0923-0057
Exp. Date 10/31/2026

ATSDR estimates the average public reporting burden for this collection of information as 10 minutes per 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 currently 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).
Basic site information
Site name:
Zip code:
Were recommendations provided for this site?
(If yes, complete entire form. If no, end here.)
Recommendation #1
Description of recommendation (1-2 sentence max):
Select the recommendation category:
Potential health concern address (1 sentence max):
Recommendation status:
Impact on exposure:
Date recommendation was adopted, if applicable:
Status update on recommendation if not yet implemented:
Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)
Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)
Description of actions taken to follow-up on recommendations:
Recommendation #2
Description of recommendation (1-2 sentence max):
Select the recommendation category:
Potential health concern address (1 sentence max):
Recommendation status:
Impact on exposure:
Date recommendation was adopted, if applicable:
Status update on recommendation if not yet implemented:
Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)
Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)
Description of actions taken to follow-up on recommendations:
Recommendation #3
Description of recommendation (1-2 sentence max):
Select the recommendation category:
Potential health concern address (1 sentence max):
Recommendation status:
Impact on exposure:
Date recommendation was adopted, if applicable:
Status update on recommendation if not yet implemented:
Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)
Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)
Description of actions taken to follow-up on recommendations:
Recommendation #4
Description of recommendation (1-2 sentence max):
Select the recommendation category:
Potential health concern address (1 sentence max):
Recommendation status:
Impact on exposure:
Date recommendation was adopted, if applicable:
Status update on recommendation if not yet implemented:
Type(s) of stakeholder(s) involved in recommendation acceptance process:
(Select all applicable)
Type(s) of stakeholder(s) responsible for implementing recommendation:
(Select all applicable)
Description of actions taken to follow-up on recommendations:
If more than four recommendations were provided for this document, copy lines 23-27 and columns A-B and paste below as needed.

These are the display options for the drop-downs in the form. It will be hidden tab when the form is used.
Yes
Impose institutional or regulatory controls to eliminte/reduce/limit exposure
No

Evacuate/relocate exposed population
Conduct exposure Investigation
Conduct ATSDR health study
State-funded health study
Conduct/continue monitoring
Other site source/media/contamination characterization
ATSDR health education activity
State-led health education activity
Remediation (e.g. site clean up) to eliminate/reduce hazards
Restrict use of source of hazards

Community leader
Community advocacy group
Federal regulatory agency
State regulatory agency
Local regulatory agency
Other regulatory agency
Industry/Business

en tab when the form is used.
educe/limit exposure

Non-verifiable
Pending acceptance
Accepted
Implemented
Rejected
Eliminated
For the purposes of recommendations, a stakeholder will be described as any entity for which
decision-maker, etc.

Reduction
Total Elimination
Unknown

Describes a recommendation to an individual community member that cannot be verified and is therefore acceptabley deeme
Describes a recommendation that has been provided to a stakeholder, but has not yet been accepted by that stakeholder. Acc
implement the recommendation in the future, but not yet having implemented the recommendation.

Describes a recommendation that has been provided to a stakeholder, and that stakeholder accepts the recommendation and
Describes a recommendation that has been fully implemented to reduce or remove the hazardous environmental exposure to
Describes a recommendation that was rejected and not accepted or implemented by the stakeholder
Describes a recommendation that was eliminated by the health assessment due to lack of application at a follow-up date.

ecommendations, a stakeholder will be described as any entity for which a recommendation can reasonably be tracked and would impact >