Child Questionnaire - Short Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0063 can be found here:

Documents and Forms

Document Name Document Type
Child Questionnaire - Short Form Form and Instruction
Multi-site Study Child Questionnaire - Short Form M_Att15a_ChldQstnnr_ShortForm_20191212_passback_CLEAN.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Child Questionnaire - Short Form	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	n/a	Multi-site Study Child Questionnaire - Short Form	M_Att15a_ChldQstnnr_ShortForm_20191212_passback_CLEAN.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09–19–0001, ‘‘Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"	FR Citation: 76 FR 4432

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	874	874

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.