[ATSDR] Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study

OMB 0923-0063

The main goal of this cross-sectional multi-site PFAS study is to evaluate associations between measured and reconstructed historic serum levels of PFAS including PFOA, PFOS, and PFHxS, and selected health outcomes. ATSDR seeks to enroll at least 8,000 participants (6,000 adults and 2,000 children) from communities exposed to PFAS-contaminated drinking water over the first three years of the five-year cooperative agreement program. This request for change includes minor changes to the screener, manual of procedures and other documents.

The latest form for [ATSDR] Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study expires 2023-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Drinking Water Information Collection (Environmental Protection Agencies) Form and Instruction
Drinking Water Information Collection (Public Water Purveyors) Form and Instruction
Child School Record Abstraction Form and Instruction
Medical Record Abstraction - Child Form and Instruction
Medical Record Abstraction - Adult Form and Instruction
Child Neurobehavioral Test Battery Form and Instruction
Parent Neurobehavioral Test Battery Form and Instruction
Child Questionnaire - Short Form Form and Instruction
Child Questionnaire - Long Form Form and Instruction
Adult Questionnaire Form and Instruction
Blood Draw and Urine Collection Form and Instruction
Body and Blood Pressure Measures Form and Instruction
Medication List Form and Instruction
Update Contact Information Form and Instruction
Appointment Reminder Form and Instruction
Eligibility Screening Form and Instruction
0 - MSS protocol_Clean 2021-11-16.docx Supplementary Document
M_Att12_MnlPrcdres_2020-08-31.docx Supplementary Document
M_Att09_ApptTrckng_20201110.docx Supplementary Document
M_Att07b_InfrmdCnsnts_2021-05-18.docx Supplementary Document
M_Att07a_ApptCard_202011010.docx Supplementary Document
M_Att22a ATSDR PFAS Factsheet.docx Supplementary Document
1 - SSB MSS 2023.docx Supporting Statement B
1 - SSA MSS 20230426_final.docx Supporting Statement A
M_Att22_PFASChemReport_20211116.docx Supplementary Document
M_Att21_ClinicalTestResultsReport_20211116.docx Supplementary Document
M_Att20b_LetterRprtCriticalValue_20191212.docx Supplementary Document
M_Att20a_AdvncClinicalTestReportTrackingForm_20191212.docx Supplementary Document
M_Att20_AdvReportScriptClinicalTests_20191212.docx Supplementary Document
M_Att19_BodyBloodPressMsReport_20191212.docx Supplementary Document
M_Att18a_NBT - TimeEstAgeinYears_20191212.docx Supplementary Document
M_Att07c_StudyFactSheet_20191212_passback_CLEAN.docx Supplementary Document
M_Att06_RecrTrackingForm_20191212.docx Supplementary Document
M_Att05_Multi-siteStudyRecrtmMaterials_20191212.docx Supplementary Document
M_Att03_JustificationSampleSizeCalcs 20191212.docx Supplementary Document
M_Att02_BiochemAnalPlanChildrenAdults 20211116.docx Supplementary Document
M_Att01_InvestigatorsKeyPersonnel_20191212.docx Supplementary Document
1 - AppndxG Data Sharing and Disclosure Review (Multi-site Study) 20190725.docx Supplementary Document
1 - AppndxF IRB Approval Memo.docx Supplementary Document
1 - AppndxE Privacy Impact Assessment 20230425signed.pdf Supplementary Document
1 - AppndxD Pease_Feasibility_Assessment_November-2017_508.pdf Supplementary Document
1 - AppndxC NOFO No. CDC-RFA-TS-19-002 rev 20190531.pdf Supplementary Document
1 - AppndxB 60D FRN.pdf Supplementary Document
1 - AppndxA Authorizing Legislation Multi-site Study.docx Supplementary Document
Drinking Water Information Collection (Environmental Protection Agencies) Form and Instruction
Drinking Water Information Collection (Public Water Purveyors) Form and Instruction
Child School Record Abstraction Form and Instruction
Request for Child School Record Abstraction Other-Letter of Request to School Administrator with Study Infor
Medical Record Abstraction - Child Form and Instruction
Medical Record Abstraction - Adult Form and Instruction
Request for Medical Record Abstraction Other-Letter of Request to Provider with Study Information
Child Neurobehavioral Test Battery Form and Instruction
Parent Neurobehavioral Test Battery Form and Instruction
Child Questionnaire - Short Form Form and Instruction
Child Questionnaire - Long Form Form and Instruction
Adult Questionnaire Form and Instruction
Blood Draw and Urine Collection Form and Instruction
Body and Blood Pressure Measures Form and Instruction
Medication List Form and Instruction
Update Contact Information Form and Instruction
Appointment Reminder Form and Instruction
Eligibility Screening Form and Instruction

All Historical Document Collections

202305-0923-001 Approved without change	Revision of a currently approved collection	2023-05-16
202010-0923-002 Approved with change	No material or nonsubstantive change to a currently approved collection	2020-10-28
202007-0923-001 Approved with change	No material or nonsubstantive change to a currently approved collection	2020-07-22
202001-0923-002 Approved with change	New collection (Request for a new OMB Control Number)	2020-01-07
201908-0923-002 Withdrawn	New collection (Request for a new OMB Control Number)	2019-12-23

OMB Details

Eligibility Screening

Federal Enterprise Architecture: Health - Public Health Monitoring

Form none

Eligibility screener

Fillable Fileable

Form and instruction

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