Perfluorinated Compound Biological Sampling in the Vicinity of Morgan, Lawrence, and Limestone Counties, Alabama

ATSDR Exposure Investigations (EIs)

OMB: 0923-0048

IC ID: 217773

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0048 can be found here:

Documents and Forms

Document Name Document Type
Perfluorinated Compound Biological Sampling in the Vicinity of Morgan, Lawrence, and Limestone Counties, Alabama Form and Instruction
PFC Exposure Investigation / Blood and Urine Sampling Qu Decatur EI OMB Package Attachment 4 - Questionnaire 07152015.docx Form and Instruction
Decatur EI OMB Package Attachment 3A - (Clean).docx 18 years of age) IC Document
Decatur EI OMB Package Attachment 3B 07152015.docx 18 years of age) IC Document
Decatur EI OMB Package Attachment 3C 07152015.docx Children's Assent Form for Blood and Urine PFC Testing and Questionnaire (12 - IC Document
Decatur EI OMB Package Attachment 3D 07152015.docx Children's Assent Form for Storage of Blood Sample for Use in Future Research (12 - < 18 years of age) IC Document
Decatur EI OMB Package Attachment 3E 07152015.docx Parental Permission Form for Blood and Urine PFC Testing and Questionnaire for Children (12 - < 18 years of age) Participating i IC Document
Decatur EI OMB Package Attachment 3F 07152015.docx Parental Permission Form for Storage of Blood Sample for Use in Future Research for Children (12 - IC Document
OMB Comment_Decatur EI OMB Package GenIC Submission Form - 08042015.docx GenIC Submission Form IC Document
Decatur EI, OMB Package, Attachment 5 - Research Determination Form.pdf Research Determination IC Document
Decatur EI, OMB Package, Attachment 6 - Draft Letters, 04272015.docx Sample Results Letter IC Document
Decatur EI, OMB Package, Attachment 7 - Example EI.docx Example of Prior Exposure Investigation Final Report IC Document
Decatur EI, OMB Package, Attachment 8 - CDC IRB Approval #6718.docx IRB Approval of CDC Protocol #6718 IC Document
Decatur EI Supporting Statement A - 06AUG2015.docx Supporting Statement A IC Document
Decatur EI Supporting Statement B - 06AUG2015.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Perfluorinated Compound Biological Sampling in the Vicinity of Morgan, Lawrence, and Limestone Counties, Alabama	Agency IC Tracking Number:	15AUQ

IC Status: New

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	NA	PFC Exposure Investigation / Blood and Urine Sampling Questionnaire	Decatur EI OMB Package Attachment 4 - Questionnaire 07152015.docx	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 53 FR 30702

Number of Respondents: 155	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	465	465
Annual IC Time Burden (Hours)	93	93
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Adult Consent Form for Blood and Urine PFC Testing and Questionnaire (>18 years of age)	Decatur EI OMB Package Attachment 3A - (Clean).docx	08/05/2015
Adult Consent Form for Storage of Blood Sample for Use in Future Research (> 18 years of age)	Decatur EI OMB Package Attachment 3B 07152015.docx	08/05/2015
Children's Assent Form for Blood and Urine PFC Testing and Questionnaire (12 - <18 years of age)	Decatur EI OMB Package Attachment 3C 07152015.docx	08/05/2015
Children's Assent Form for Storage of Blood Sample for Use in Future Research (12 - < 18 years of age)	Decatur EI OMB Package Attachment 3D 07152015.docx	08/05/2015
Parental Permission Form for Blood and Urine PFC Testing and Questionnaire for Children (12 - < 18 years of age) Participating in Investigation	Decatur EI OMB Package Attachment 3E 07152015.docx	08/05/2015
Parental Permission Form for Storage of Blood Sample for Use in Future Research for Children (12 - <18 years of age) Participating in Investigation	Decatur EI OMB Package Attachment 3F 07152015.docx	08/05/2015
GenIC Submission Form	OMB Comment_Decatur EI OMB Package GenIC Submission Form - 08042015.docx	08/05/2015
Research Determination	Decatur EI, OMB Package, Attachment 5 - Research Determination Form.pdf	08/05/2015
Sample Results Letter	Decatur EI, OMB Package, Attachment 6 - Draft Letters, 04272015.docx	08/05/2015
Example of Prior Exposure Investigation Final Report	Decatur EI, OMB Package, Attachment 7 - Example EI.docx	08/05/2015
IRB Approval of CDC Protocol #6718	Decatur EI, OMB Package, Attachment 8 - CDC IRB Approval #6718.docx	08/05/2015
Supporting Statement A	Decatur EI Supporting Statement A - 06AUG2015.docx	08/06/2015
Supporting Statement B	Decatur EI Supporting Statement B - 06AUG2015.docx	08/06/2015

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