OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Assessment of Potential Exposure from Private Wells for Drinking Water

ICR 201606-0920-005 · OMB 0920-1173 · Historical Active

Forms and Documents
Document
Name
Status
Form and Instruction
 New
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2017-03-30
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-22
Supplementary Document
2016-06-09
Supplementary Document
2016-06-09
Supplementary Document
2016-06-09
Supplementary Document
2016-06-09
Supplementary Document
2016-06-09
Supporting Statement B
2017-03-30
Supporting Statement A
2017-03-30
IC Document Collections
IC ID
Document
Title
Status
237560 New
ICR Details
0920-1173 201606-0920-005
Historical Active
HHS/CDC 0920-16TL
Assessment of Potential Exposure from Private Wells for Drinking Water
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 03/30/2017
Retrieve Notice of Action (NOA) 06/23/2016
Approved consistent with the understanding that collections submitted under this generic are not considered research and will not include epidemiological studies or the collection of health data. Each GenIC will include a full supporting statement Part A and B.
  Inventory as of this Action Requested Previously Approved
03/31/2020 36 Months From Approved
19,500 0 0
6,252 0 0
141,987 0 0
There is no comprehensive knowledge about the locations of private wells, the populations served by these sources, potential contaminants that might be present in private well water in specific areas of the country, or the potential health risks associated with drinking water from these sources. The goal of this generic clearance information collection request (Generic ICR) is to expedite investigations of private well water for drinking in response to specific investigation requests. Each investigation will assess exposure to contaminants in drinking water from private wells in a geographic area specified by the requesting entity. Requesting entities may be any state, territorial, local, or tribal health department in the United States. Methods to collect data include questionnaires and analysis of clinical specimens and/or environmental samples.
US Code: 42 USC 241 Name of Law: U.S. Public Health Service Act
  
None
Not associated with rulemaking
  81 FR 12902 03/11/2016
81 FR 40703 06/22/2016
Yes
1
IC Title Form No. Form Name
Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire 0920-1173, 0920-1173, 0920-1173, 0920-1173 Screening Survey ,   Consent Form ,   Food and Bathing Log ,   Survey
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 19,500 0 0 19,500 0 0
Annual Time Burden (Hours) 6,252 0 0 6,252 0 0
Annual Cost Burden (Dollars) 141,987 0 0 141,987 0 0
Yes
Miscellaneous Actions
No
Submission of 0920-16TL is a New Generic ICR. Burden values reflect Total Responses and Burden Hours for period of three years.
$441,200
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Jeffrey Zirger 404 639-7118 wtj5@cdc.gov
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/23/2016