Public Comments

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Comments of Persistence Analytics Group LLC Regarding APPLETREE Performance Measures
Docket No. ATSDR-2026-0067
OMB Control No. 0923-0057
Public Comment Received:  
Persistence Analytics Group LLC submits these comments regarding the Agency for Toxic Substances and Disease Registry’s proposed revision of the APPLETREE Performance Measures information collection. 

PAG supports ATSDR’s continued collection of performance information for the APPLETREE cooperative agreement program. Environmental exposure programs should be evaluated not only by administrative activity, but by whether public-health risk assumptions are identified, verified, acted upon, and followed through to measurable risk reduction. 

ATSDR’s notice explains that APPLETREE helps recipients identify exposure pathways, educate affected communities, make recommendations to prevent exposure, review health outcome data, and document the effects of environmental remediation on health. Those are exactly the right categories. The performance-measure framework should make sure those categories produce decision-grade information. 

The practical utility of the collection would be strengthened if ATSDR ensured the measures can answer the following questions: 
 
1. What exposure risk was identified? 
2. What evidence supports the exposure pathway? 
3. What population, facility, school, workplace, neighborhood, or community may be affected? 
4. What recommendation was made? 
5. Who owns implementation of the recommendation? 
6. What action was taken? 
7. What risk remains unresolved? 
8. What changed because APPLETREE intervened? 
9. What evidence shows exposure was reduced or prevented? 
10. What should trigger follow-up review? 

PAG recommends that ATSDR distinguish among four categories of performance: 
 
First, activity measures: meetings, forms, consultations, education sessions, technical assistance, screenings, and reports. 
 
Second, evidence measures: exposure pathway identified, contaminant source characterized, affected population estimated, health outcome data reviewed, and uncertainty documented. 
 
Third, action measures: recommendation issued, responsible party identified, intervention initiated, site-siting decision changed, exposure pathway interrupted, or remediation linked to health protection. 
 
Fourth, outcome and follow-up measures: recommendation status, unresolved risk, exposure reduction evidence, community notification, and whether additional review is needed. 
 
This distinction is important because activity is not the same as public-health protection. A program can generate reports, education sessions, technical assistance responses, and success stories while still leaving core exposure assumptions unresolved. 
 
ATSDR should also ensure that Recommendation Follow-up reporting captures whether recommendations were implemented, partially implemented, rejected, delayed, or still pending, and whether any remaining exposure risk is understood by the affected community and responsible agencies. 
 
PAG supports burden discipline. The notice estimates a total annual burden of 269 hours across 30 funded recipients. That burden appears modest relative to the public-health importance of evaluating hazardous-substance exposure, but the information collected should be structured to produce practical, comparable, and actionable evidence. 
 
The broader principle is simple: 
 
Public-health performance measures should distinguish administrative activity from verified exposure-risk reduction. 
 
For APPLETREE, the performance question should not be only: 
 
What did the recipient do? 
 
It should also be: 
 
What exposure assumption was tested? 
What evidence was found? 
What action followed? 
What risk was reduced? 
What risk remains? 
 
PAG recommends approval of the revised information collection, with emphasis on strengthening evidence quality, recommendation follow-up, exposure-pathway verification, unresolved-risk tracking, and practical utility for communities and decision-makers. 




Response

ATSDR appreciates your comments regarding the information collection under OMB Control No. 0923-0057. Under our statutory mandate in the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), as amended, ATSDR and its state cooperative agreement partners evaluate health risks from hazardous substances through public health assessment documents, including Public Health Assessments (PHAs), Health Consultations (HCs), Letter Health Consultations (LHCs). This cooperative agreement also provides health education and outreach at the state level to promote and achieve the safe siting of childcare facilities in the United States. The purpose of this information collection request (ICR) is to support program planning and management related to recipient progress reporting, financial reporting and grants management, and quality control. 

We summarized your comments in the following topics and provided our responses to each topic below. 

Ten Questions on Exposure Assessment, Recommendations, and Follow-up
The 10 questions identified represent core components of the public health assessment process that is conducted at each site. Comprehensive scientific and toxicological evaluations, exposure pathway, identified contaminants, affected populations, assessment results and findings, recommendations, and public health actions are documented within individual site-specific PHA, HC, and LHC reports. For detailed information on public health assessment process, including how the assessments address various areas in your questions, please visit https://www.atsdr.cdc.gov/pha-guidance/index.html.  Operational tracking (such as recommendation implementation and actions taken) is captured across the Site Impact Assessment (SIA), Technical Assistance (TA), Health Education (HE), and Recommendation Follow-up forms. Because APPLETREE is a non-research cooperative agreement, longitudinal epidemiological studies to establish long-term chronic disease reduction exceed the programmatic scope of this program. Finally, follow-up review would be triggered by request if/when new environmental sampling data are available. 

Four Performance Categories
Regarding the four proposed performance categories:
    • Activity Measures are captured via the TA and HE forms;
    • Evidence Measures are established through scientific site evaluations, reported and documents in each published site-specific PHA/HC/LHC;
    • Action Measures: For each site, recommendations for various parties and public health actions are documented in each published site-specific PHA/HC/LHC.  
    • Outcome/Follow-up Measures are systematically tracked via the SIA and Recommendation Follow-up forms.

The existing forms already capture these data points.

Burden Hour Estimates
The estimated annual burden of 269 hours across 30 funded recipients accounts only for the administrative time required under the Paperwork Reduction Act (PRA) for staff to enter, track, and submit reporting data. It is not intended to reflect the entirety of the substantive public health work, environmental data analysis, toxicological evaluations, community engagement, or document preparation performed by recipient programs.

Five “What” Questions 
ATSDR concurs that public health performance measures should distinguish administrative activity from verified exposure-risk reduction. While this ICR is focused on program-level administrative reporting, the questions on exposure assessment, evidence, findings, recommendations, and public health actions are site-specific and provided in the PHAs/HCs/LHCs for each site. 

Because the current and proposed collection instruments capture necessary programmatic, operational, and recommendation-tracking data without imposing redundant burden on funded recipients, ATSDR will proceed with submitting the information collection request to OMB for approval without structural modifications to the forms.