ATSDR Site Impact Assessment Form

APPLETREE Performance Measures

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Document Name Document Type
ATSDR Site Impact Assessment Form Form and Instruction
Att4c SIA Form_Word 20200325.docx Other-Word document to display instr
Site Impact Assessment Form Att4c SIA Form_Screenshots 20200325.docx Form and Instruction

Information Collection (IC) Details

IC Title:	ATSDR Site Impact Assessment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	Site Impact Assessment Form	Att4c SIA Form_Screenshots 20200325.docx		Yes	Yes	Fillable Fileable
Other-Word document to display instrument content			Att4c SIA Form_Word 20200325.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	487	487

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.