[ATSDR] Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study

ICR 202305-0923-001

OMB: 0923-0063

Federal Form Document

Forms and Documents

Document Name	Status
Drinking Water Information Collection (Environmental Protection Agencies) Form and Instruction	Unchanged
Drinking Water Information Collection (Public Water Purveyors) Form and Instruction	Unchanged
Child School Record Abstraction Form and Instruction	Modified
Medical Record Abstraction - Child Form and Instruction	Modified
Medical Record Abstraction - Adult Form and Instruction	Modified
Child Neurobehavioral Test Battery Form and Instruction	Modified
Parent Neurobehavioral Test Battery Form and Instruction	Modified
Child Questionnaire - Short Form Form and Instruction	Modified
Child Questionnaire - Long Form Form and Instruction	Modified
Adult Questionnaire Form and Instruction	Modified
Blood Draw and Urine Collection Form and Instruction	Modified
Body and Blood Pressure Measures Form and Instruction	Modified
Medication List Form and Instruction	Modified
Update Contact Information Form and Instruction	Modified
Appointment Reminder Form and Instruction	Modified
Eligibility Screening Form and Instruction	Modified
0 - MSS protocol_Clean 2021-11-16.docx Supplementary Document	2023-05-12
M_Att12_MnlPrcdres_2020-08-31.docx Supplementary Document	2023-05-12
M_Att09_ApptTrckng_20201110.docx Supplementary Document	2023-05-12
M_Att07b_InfrmdCnsnts_2021-05-18.docx Supplementary Document	2023-05-12
M_Att07a_ApptCard_202011010.docx Supplementary Document	2023-05-12
M_Att22a ATSDR PFAS Factsheet.docx Supplementary Document	2023-05-12
1 - SSB MSS 2023.docx Supporting Statement B	2023-05-11
1 - SSA MSS 20230426_final.docx Supporting Statement A	2023-05-15
M_Att22_PFASChemReport_20211116.docx Supplementary Document	2023-05-12
M_Att21_ClinicalTestResultsReport_20211116.docx Supplementary Document	2023-05-12
M_Att20b_LetterRprtCriticalValue_20191212.docx Supplementary Document	2023-05-12
M_Att20a_AdvncClinicalTestReportTrackingForm_20191212.docx Supplementary Document	2023-05-12
M_Att20_AdvReportScriptClinicalTests_20191212.docx Supplementary Document	2023-05-12
M_Att19_BodyBloodPressMsReport_20191212.docx Supplementary Document	2023-05-12
M_Att18a_NBT - TimeEstAgeinYears_20191212.docx Supplementary Document	2023-05-12
M_Att07c_StudyFactSheet_20191212_passback_CLEAN.docx Supplementary Document	2023-05-12
M_Att06_RecrTrackingForm_20191212.docx Supplementary Document	2023-05-12
M_Att05_Multi-siteStudyRecrtmMaterials_20191212.docx Supplementary Document	2023-05-12
M_Att03_JustificationSampleSizeCalcs 20191212.docx Supplementary Document	2023-05-12
M_Att02_BiochemAnalPlanChildrenAdults 20211116.docx Supplementary Document	2023-05-12
M_Att01_InvestigatorsKeyPersonnel_20191212.docx Supplementary Document	2023-05-12
1 - AppndxG Data Sharing and Disclosure Review (Multi-site Study) 20190725.docx Supplementary Document	2023-05-11
1 - AppndxF IRB Approval Memo.docx Supplementary Document	2023-05-11
1 - AppndxE Privacy Impact Assessment 20230425signed.pdf Supplementary Document	2023-05-11
1 - AppndxD Pease_Feasibility_Assessment_November-2017_508.pdf Supplementary Document	2023-05-11
1 - AppndxC NOFO No. CDC-RFA-TS-19-002 rev 20190531.pdf Supplementary Document	2023-05-11
1 - AppndxB 60D FRN.pdf Supplementary Document	2023-05-11
1 - AppndxA Authorizing Legislation Multi-site Study.docx Supplementary Document	2023-05-11

IC Document Collections

IC ID	Document Title	Status
242013	Drinking Water Information Collection (Environmental Protection Agencies) Form and Instruction	Unchanged
242012	Drinking Water Information Collection (Public Water Purveyors) Form and Instruction	Unchanged
239069	Child School Record Abstraction Form and Instruction	Modified
239068	Request for Child School Record Abstraction Other-Letter of Request to School Administrator with Study Infor	Modified
239067	Medical Record Abstraction - Child Form and Instruction	Modified
239066	Medical Record Abstraction - Adult Form and Instruction	Modified
239065	Request for Medical Record Abstraction Other-Letter of Request to Provider with Study Information	Modified
239061	Child Neurobehavioral Test Battery Form and Instruction	Modified
239060	Parent Neurobehavioral Test Battery Form and Instruction	Modified
239059	Child Questionnaire - Short Form Form and Instruction	Modified
239058	Child Questionnaire - Long Form Form and Instruction	Modified
239057	Adult Questionnaire Form and Instruction	Modified
239056	Blood Draw and Urine Collection Form and Instruction	Modified
239053	Body and Blood Pressure Measures Form and Instruction	Modified
239052	Medication List Form and Instruction	Modified
239051	Update Contact Information Form and Instruction	Modified
239050	Appointment Reminder Form and Instruction	Modified
239035	Eligibility Screening Form and Instruction	Modified