Household Recruitment Script for Environmental Sampling

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

Documents and Forms

Document Name Document Type
Household Recruitment Script for Environmental Sampling Form and Instruction
Household Recruitment Script for Environmental Sampling PrtApndxA4_HHRecrtScrptEnvSampling_20220609.docx Form and Instruction
Household Recruitment Script for Environmental Sampling PrtApndxA4_HHRecrtScrptEnvSampling_20220609.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Household Recruitment Script for Environmental Sampling	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	Household Recruitment Script for Environmental Sampling	PrtApndxA4_HHRecrtScrptEnvSampling_20220609.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: 70	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	Previously Approved
Annual Number of Responses for this IC	70	-47	117
Annual IC Time Burden (Hours)	6	-4	10
Annual IC Cost Burden (Dollars)	168	-70	238

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.