Water Information Collection Form for Environmental Prot

Attachment 3d.

Form Approved

OMB No. 0923-00xx

Exp. Date xx/xx/20xx

Multi-site Study

Eligibility Screening Script

Flesch-Kincaid Readability Score – 5.8

Drinking Water Information Collection Form for Environmental Protection Agencies

1. Is the site served by a public water supply?

If yes, the following information will be requested from the water purveyor:

• List of residences served by the water purveyor

  • Name of person and street address

• Distribution system characteristics

  • Specifically, whether the PFAS concentrations can be assumed to be relatively uniform throughout the system or whether the system had specific areas with substantially higher or lower PFAS concentrations.

  • Sources of drinking water (e.g., supply wells, reservoir)

  • Any interconnections between water systems; if so, then frequency of use of the interconnection and the amount of water supplied by the interconnection when in use

• If distribution system characteristics indicate supply wells, the following information will be requested

  • Historical and current supply well information

    • Monthly/Daily production logs

    • Dates of operation

• Results from all relevant PFAS sampling

If no, please proceed to question 2.

2. Does the site have contaminated private wells?

ATSDR estimates the average public reporting burden for this collection of information as 7 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

If yes, the following information will be requested from state and/or local health and environmental agencies:

• List of residences with a contaminated private well

  • Name of person and street address

• Results from all relevant PFAS sampling of private wells