OMB control number

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

OMB 0923-0059 · HHS/TSDR.

OMB 0923-0059

This information collection addresses the requirements for completing exposure assessments (EAs) for PFAS authorized in Section 8006 of the Consolidated Appropriations Act, 2018. ATSDR/NCEH will use statistical methods to recruit respondents at a minimum of eight current or former domestic military installations known to have PFAS contamination in water sources. ATSDR will collect biological and environmental samples to evaluate exposure. This request for non-material change will enable virtual meetings and telephone interviews instead of in-person contact. The changes are being made due to COVID-19 precautions and the need to practice social distancing.

The latest form for Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs) expires 2022-06-30 and is listed under ICR 202006-0923-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
EA Participants (All Ages) - Biological Testing Tracking	Form
Environmental Sample Collection Form	Form
Environmental Sampling Consent	Form
Household Recruitment Script for Environmental Sampling	Form and Instruction
Exposure Questionnaire for Biological Testing - Child Completed	Form
Child Assent	Form and Instruction
Exposure Questionnaire for Biological Testing - Parent Proxy	Form
Parental Permission	Form
Adult Exposure Assessment Questionnaire	Form
Adult Consent	Form
Household Eligibility Screener	Form and Instruction
Community Event Evaluation Survey	Form
PrtApndxK_Crosswalk table for Protocol Modifications.xlsx	Supplementary Document
PrtApndxJ_PFAS EA Restart Plan_v8.docx	Supplementary Document
PrtApndxC1_SampleCollectionLog_20191108.docx	Supplementary Document
PrtApndxB1_PrivacyActStatement_20191108.docx	Supplementary Document
PrtApndxA2_HHRecruitmentLetter_20220609.docx	Supplementary Document
PFAS Exposure Assessment Protocol Revision clean.docx	Supplementary Document
PrtApndxE_UrineCollctnInstrctns_20191108.docx	Supplementary Document
PrtApndxD_ChainCustodyForms_20191108.docx	Supplementary Document
PrtApndxI_Data MangmntPlan_revision clean.docx	Supplementary Document
PrtApndxH_SiteHlthSafety Plan_06_02_2020.docx	Supplementary Document
1 - PFAS EA SSB_2022_6_1_22.docx	Supporting Statement B
1 - PFAS EA SSA_2022_6_1_22.docx	Supporting Statement A
PrtApndxG2_RsultsLttrEnviroSmpling 20200109.docx	Supplementary Document
PrtApndxG1_RsultsLttrBiolgcSmplng 20200109.docx	Supplementary Document
Att6 STARS Determination.pdf	Supplementary Document
Att5 PIA_PFAS EA signed OCISO 20220509.pdf	Supplementary Document
Att4 PFAS EA Example report-508.pdf	Supplementary Document
Att3 PFAS EA Technical Tools (PEATT).pdf	Supplementary Document
Att2 0923-0059 PFAS EA 60D FRN.pdf	Supplementary Document
Att1 AuthLegsl PFAS EA.docx	Supplementary Document
EA Participants (All Ages) - Biological Testing Tracking	Form
Environmental Sample Collection Form	Form
Environmental Sampling Consent	Form
Household Recruitment Script for Environmental Sampling	Form and Instruction
Exposure Questionnaire for Biological Testing - Child Completed	Form
Child Assent	Form and Instruction
Exposure Questionnaire for Biological Testing - Parent Proxy	Form
Parental Permission	Form
Adult Exposure Assessment Questionnaire	Form
Adult Consent	Form
Household Eligibility Screener	Form and Instruction
Community Event Evaluation Survey	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202206-0923-001	Revision of a currently approved collection	2022-06-17	Approved without change
202006-0923-001	No material or nonsubstantive change to a currently approved collection	2020-06-18	Approved with change
202002-0923-001	No material or nonsubstantive change to a currently approved collection	2020-02-14	Approved without change
202001-0923-004	No material or nonsubstantive change to a currently approved collection	2020-01-31	Approved without change
202001-0923-003	No material or nonsubstantive change to a currently approved collection	2020-01-10	Improperly submitted and continue
201907-0923-001	No material or nonsubstantive change to a currently approved collection	2019-07-29	Approved without change
201811-0923-001	New collection (Request for a new OMB Control Number)	2018-11-29	Approved with change

OMB Details

Community Event Evaluation Survey

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
Form	Name	Electronic access	Type
Form none	Exposure assessment community event survey	Paper Only	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.