Form 0923-0060 EHLR Privacy Act Opt Out Form

Attachment 3b. EHLR Privacy Act Opt Out Form

Form Approved

OMB No. 0923-0060

Exp. Date 08/31/2022

EHLR Privacy Act Opt Out Form

ATSDR estimates the average public reporting burden of this collection of information as 1 minute 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 H21-8 Atlanta, Georgia 30333; ATTN: PRA (0923-0060)

Thank you for registering for the Environmental Health Land Reuse (EHLR) Training. The Agency for Toxic Substances and Disease Registry (ATSDR) will be sharing participant names and email addresses with the National Environmental Health Association (NEHA). NEHA will issue Certificates of Completion and Continuing Education Units (CEUs) to participants who successfully complete this training.

Use this form to indicate you do not want ATSDR to share your personal information with NEHA, and that you opt out of receiving a Certificate of Completion and CEUs. You are welcome to attend and complete the training otherwise.

I opt out of allowing ATSDR to share my name and email address with NEHA. I understand that I will not receive a Certificate of Completion or CEUs. I understand that I can still participate in training.
Course Name:
Course Date:
First Name:
Last Name:
Email:

PRIVACY ACT STATEMENT

FOR THE

ATSDR ENVIRONMENTAL HEALTH LAND REUSE TRAINING PROGRAM

This statement provides the notice required by the Privacy Act of 1974 (5 USC § 552(a)(e)(3)).

• Authority: The Agency for Toxic Substances and Disease Registry (ATSDR has the authority to collect this information under 42 U.S. Code Chapter 103 – Comprehensive Environmental Response, Compensation, and Liability.

• Purpose: ATSDR is collecting participant training information, such as registration and self-assessments related to the environmental health land reuse course content developed by ATSDR.

• Routine Uses:

  • ATSDR will share your name and email address with the National Environmental Health Association (NEHA) upon successful completion of course requirements. NEHA will issue Certificates of Completion and Continuing Education Units (CEUs).

  • Other routine uses as described in System of Records Notice (SORN) No. 09-20-0161 (Records of Health Professionals in Disease Prevention and Control Training Programs, HHS/CDC/NCPS). Name of individual respondent, identification number, and type of training received are some of the indices used to retrieve records from this system. See https://www.hhs.gov/foia/privacy/sorns/09200161/index.html.

• Disclosure: Providing registration information is voluntary but is required to attend training. You may opt out of allowing ATSDR to share this information with NEHA and still participate in training. If you opt out, you will not receive a Certificate of Completion or CEUs.