ATSDR Technical Assistance (TA) Activity Form

Attachment 4b. ATSDR Technical Assistance (TA) Activity Form (Word)

Form Approved OMB Control Number: 0923-0057 Expiration Date: 07/31/2020 ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).
Technical Assist Details
Actual Start Date:	[date field]
Complete Date:	[date field]
Health Assessor:	[drop-down options] ATSDR Staff
Response Summary	[free text field]