Adult and Adolescent Questionnaire

Supplemental Measurements for Exploratory Research regarding Exposure during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0062 can be found here:

Documents and Forms

Document Name Document Type
Form 0923-19GW Adult and Adolescent Questionnaire Form and Instruction
0923-19GW Adult/Ado Field Questionnaire Att3e_Adult-AdoQx.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Adult and Adolescent Questionnaire	Agency IC Tracking Number:	0923-19GW

Is this a Common Form? No		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	0923-19GW	Adult/Ado Field Questionnaire	Att3e_Adult-AdoQx.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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