Child Questionnaire - Short Form

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
Child Questionnaire - Short Form Form
Child Questionnaire - Short Form P_Att17a_PeaseChildQstnnr_ShortForm 20190813 clean.docx Form
Child Questionnaire - Short Form P_Att17a_PeaseChildQstnnr_ShortForm 20190813 clean.docx Form

Information Collection (IC) Details

IC Title:	Child Questionnaire - Short Form	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	none	Child Questionnaire - Short Form	P_Att17a_PeaseChildQstnnr_ShortForm 20190813 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: 35	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	35	35
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	219	219

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.