Information Collection

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire

IC 237560 under ICR 201606-0920-005 · OMB 0920-1173.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1173 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1173 Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire Form and Instruction
0920-1173 Screening Survey AttC_Screening Survey.docx Form and Instruction
0920-1173 Consent Form AttD_Consent Form.docx Form and Instruction
0920-1173 Food and Bathing Log AttE_FoodandBathing Log.docx Form and Instruction
0920-1173 Survey AttG_Survey_OMBrevisions_clean.docx Form and Instruction
AttA_Letters of Collaboration.pdf Letters of Collaboration IC Document
AttB_Invitation Letter.docx Invitation Letter IC Document
AttF_Urine Collection Directions.docx Urine Collection Directions IC Document
AttH_Participant Results Letter_OMBrevisions_20190820 tracked changes omb.docx Results Letter IC Document
AttI_Research Determination Form.pdf Research Determination Form IC Document
Request to use Generic Clearance Form.docx Request for Generic Clearance Form IC Document
SSA_Exposure to Arsenic and Uranium in Private Well Water.docx SSA IC Document
SSB_Exposure to Arsenic and Uranium in Private Well Water.docx SSB IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire	Agency IC Tracking Number:	0920-1173-19BLL

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	0920-1173	Screening Survey	AttC_Screening Survey.docx	No	Fillable Fileable
Form and Instruction	0920-1173	Consent Form	AttD_Consent Form.docx	No	Fillable Fileable
Form and Instruction	0920-1173	Food and Bathing Log	AttE_FoodandBathing Log.docx	No	Fillable Fileable
Form and Instruction	0920-1173	Survey	AttG_Survey_OMBrevisions_clean.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,900	1,900
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letters of Collaboration	AttA_Letters of Collaboration.pdf	08/27/2019
Invitation Letter	AttB_Invitation Letter.docx	08/27/2019
Urine Collection Directions	AttF_Urine Collection Directions.docx	08/27/2019
Results Letter	AttH_Participant Results Letter_OMBrevisions_20190820 tracked changes omb.docx	08/27/2019
Research Determination Form	AttI_Research Determination Form.pdf	08/27/2019
Request for Generic Clearance Form	Request to use Generic Clearance Form.docx	08/27/2019
SSA	SSA_Exposure to Arsenic and Uranium in Private Well Water.docx	08/27/2019
SSB	SSB_Exposure to Arsenic and Uranium in Private Well Water.docx	08/27/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.