Wave Three Eligibility Screening Script

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

Documents and Forms

Document Name Document Type
Form 0923-0061 Wave Three Eligibility Screening Script Form and Instruction
0923-0061 Wave Three Eligibility Script P_Att07c WaveTwoorWaveThreeElgbltyScreeningScript_20200803_clean.docx Form and Instruction
0923-0061 Wave Three Eligibility Script P_Att07c WaveTwoorWaveThreeElgbltyScreeningScript_20200803_clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Wave Three Eligibility Screening Script	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	0923-0061	Wave Three Eligibility Script	P_Att07c WaveTwoorWaveThreeElgbltyScreeningScript_20200803_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 121	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	121	121
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	756	756

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.