OMB control number

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

OMB 0923-0063 · HHS/TSDR.

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 is listed under ICR 202010-0923-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
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 (document unavailable)	Supplementary Document
M_Att07a_ApptCard_202011010.docx (document unavailable)	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

Historical document collections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201908-0923-002	New collection (Request for a new OMB Control Number)	2019-12-23	Withdrawn

OMB Details

Eligibility Screening

Federal Enterprise Architecture: Health - Public Health Monitoring

Information collection instruments
Form	Name	Electronic access	Type
Form none	Eligibility screener	Fillable Fileable	Form and instruction

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