NCEH/ATSDR Exposure Investigations (EI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0040 can be found here:

Documents and Forms

Document Name Document Type
Form no form number NCEH/ATSDR Exposure Investigations (EI) Form and Instruction
no form number Chemical Exposure Questions Attachment 3_Revised _Chemical Exposure Questions.doc Form and Instruction
Attachment 6. Example Human Subjects Research Determination Form.pdf Attachment 6 IC Document
Attachment 4. Combined set other agencies.doc Attachment 4 IC Document
Attachment 5. Example Consent Form.doc Attachment 5 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NCEH/ATSDR Exposure Investigations (EI)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	no form number	Chemical Exposure Questions	Attachment 3_Revised _Chemical Exposure Questions.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-19-001 Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (ATSDR)	FR Citation: 57 FR 62814

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	700	-50	750
Annual IC Time Burden (Hours)	350	-25	375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 6	Attachment 6. Example Human Subjects Research Determination Form.pdf	07/31/2012
Attachment 4	Attachment 4. Combined set other agencies.doc	07/31/2012
Attachment 5	Attachment 5. Example Consent Form.doc	07/31/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.