According to the "Community Assessment Example" Reading, Some of the Items They Assessed Included:

• (Department 2.1) What is a public health assessment?
• (Section 2.2) When is a public health assessment conducted?
• (Section 2.iii) Who conducts public health assessments?
• (Section 2.4) What is the role of the community in a public health assessment?
• (Section two.five) How is the public health cess conducted?
• (Department 2.half-dozen) What products and public health actions result from the cess process?
• (Section 2.7) What is the format for public wellness cess documents?

This chapter introduces the public health cess process and serves equally a road map to the rest of the manual. Information technology provides an overview of the various steps in the procedure, introduces the multi-disciplinary team arroyo that you will use for most of your public health assessments, and describes the specific role of the wellness assessor and team leader and how diverse squad members fit into the procedure. Throughout this manual, the public wellness assessment procedure will be distinguished from the public health assessment document. Henceforth, the acronym "PHA" will be used exclusively to refer to the PHA document (whereas, the public health assessment process can consequence in either a PHA or a PHC).

ATSDR partners may find that some discussions in this affiliate, and the manual in general, are non necessarily relevant to their particular procedures (east.g., use of affiliated offices to manage dissimilar aspects of the public health assessment), merely the process as a whole applies to all health assessors from within or outside ATSDR. This chapter addresses the questions:

2.1 What Is a Public Health Assessment?

2.1.i Definition and Purpose

A public health assessment is formally defined equally:

The evaluation of information and information on the release of hazardous substances into the surroundings in social club to assess whatsoever [past], current, or future impact on public health, develop wellness advisories or other recommendations, and identify studies or actions needed to evaluate and mitigate or forestall human health effects (42 Code of Federal Regulations, Office 90, published in 55 Federal Register 5136, February 13, 1990).

A public health cess is conducted to determine whether and to what extent people take been, are being, or may be exposed to hazardous substances associated with a hazardous waste matter site and, if and so, whether that exposure is harmful and should be stopped or reduced. The public wellness assessment process enables ATSDR to prioritize and identify additional steps needed to respond public health questions, and defines follow-up activities needed to protect public health.

There are a number of goals of the process that you should keep in listen throughout your assessment. These are:

• Evaluate site conditions and determine the nature and extent of environmental contamination.
• Ascertain potential human being exposure pathways related to site-specific ecology contaminants.
• Identify who may be or may take been exposed to environmental contamination associated with a site (past, electric current, and time to come).
• Examine the public wellness implications of site-related exposures, through the examination of ecology and health effects information (toxicologic, epidemiologic, medical, and health outcome data).
• Address those implications past recommending relevant public health deportment to prevent harmful exposures.
• Place and respond to customs health concerns and clearly communicate the findings of the assessment.

2.ane.2 Factors to Exist Considered in All Public Wellness Assessments

Past police force, ATSDR is required to consider certain factors when evaluating possible public wellness hazards. Specifically, the Comprehensive Ecology Response, Compensation, and Liability Act (CERCLA), as amended past the Superfund Amendments and Reauthorization Act (SARA) (104 [i][6][f]) requires that, at a minimum, public health assessments consider the following factors. This manual describes an approach to conducting public health assessments that incorporates each of them.

• Nature and extent of contamination—What is the spatial and temporal extent of site-related contagion? Have contaminants migrated off site? What media have been and/or continue to be affected (due east.thousand., water, soil, air, food chain [biota])?
• Demographics (population size and susceptibility)—Who is existence exposed, and do any special populations need to exist considered (e.g., children, women of child-bearing age, fetuses, lactating women, the elderly)?
• Pathways of human exposure (past, electric current, and future)—How might people be exposed to site-related contamination (e.g., drinking h2o, breathing air, directly skin contact)? What are the site-specific exposure atmospheric condition (e.g., duration, frequency, and magnitude of exposure)?
• Health effects and disease-related data—How practice expected site-specific exposure levels for the identified hazardous substances compare with the observed health event levels (from toxicologic, epidemiologic, and medical studies), and with whatever available recommended exposure or tolerance limits (e.chiliad., water quality standards)? How exercise existing morbidity and mortality data on diseases compare with observed levels of exposure?

2.one.3 How Does a Public Health Assessment Differ From a Risk Assessment?

ATSDR's public wellness assessments differ from the more quantitative hazard assessments conducted by regulatory agencies, such equally EPA. Both types of assessments try to accost the potential homo wellness furnishings of low-level environmental exposures, but they are approached differently and are used for unlike purposes. Ane needs to empathise these differences to know how to interpret and integrate the information generated by each of these assessments.

• The quantitative risk assessment is used past regulators equally part of site remedial investigations to determine the extent to which site remedial action (eastward.g., cleanup) is needed. The adventure cess provides a numeric approximate of theoretical run a risk or hazard, assuming no cleanup takes identify. It focuses on current and potential futurity exposures and considers all contaminated media regardless if exposures are occurring or are likely to occur. By design, it generally uses standard (default) protective exposure assumptions when evaluating site take a chance.
• The public wellness cess is used past ATSDR to identify possible harmful exposures and to recommend actions needed to protect public wellness. ATSDR considers the aforementioned environmental information as EPA, but focuses more closely on site-specific exposure weather, specific customs wellness concerns, and any available wellness outcome data to provide a more qualitative, less theoretical evaluation of possible public health hazards. It considers past exposures in addition to current and potential hereafter exposures.

The full general steps in the two processes are like (e.thou., data gathering, exposure assessment, toxicologic evaluation), but the public health assessment provides additional public health perspective by integrating site-specific exposure weather condition with health effects data and specific community health concerns. ATSDR'south public health cess also evaluates health effect data, when available, to identify whether rates of disease or death are elevated in a site community, specially if the community expresses business organisation near a particular consequence (e.g., cancer).

Remedial plans based on a quantitative hazard assessment represent a prudent public health approach—that of prevention. By design, yet, quantitative hazard assessments used for regulatory purposes do non provide perspective on what the hazard estimates mean in the context of the site community. The public health assessment does. The process is more than exposure driven. The process identifies and explains whether exposures are truly likely to be harmful nether site-specific conditions and recommends deportment to reduce or prevent such exposures.

2.2 When Is a Public Health Assessment Conducted?

Three situations can trigger a public health assessment:

• A site is proposed to be placed on the EPA National Priorities Listing (NPL). ATSDR is required past law to acquit a public health assessment at all sites proposed for or listed on EPA's NPL.
• ATSDR receives a "petition" to evaluate a site or release. Both CERCLA, every bit amended past SARA, and the Resource Conservation and Recovery Act (RCRA), equally amended past the Hazardous Solid Waste Amendments of 1984, allow individual and concerned parties (e.thousand., community members, physicians, land or federal agencies, or tribal governments) to petition ATSDR to conduct public health assessments. ATSDR has promulgated regulations describing the petitioned public health assessment process (42 Code of Federal Regulations, Part ninety, published in 55 Federal Register 5136, February thirteen, 1990). After the initial information gathering, ATSDR decides whether a public health cess should be conducted. Not every petition results in a public health assessment.
• ATSDR receives a request from another bureau. State and federal regulatory agencies and land, local, and tribal health departments may request that ATSDR use its public health evaluation expertise to provide a technical consultation for a proposed or completed action. In these cases, ATSDR may exist asked to evaluate data (e.g., a sampling programme, a remediation alternative) for the degree to which it is protective of public health. This type of evaluation is frequently conducted as an abbreviated public wellness assessment.

2.three Who Conducts Public Health Assessments?

ATSDR staff and its regime partners (i.e., state health departments, tribal governments, and other government organizations that have received funding through ATSDR's cooperative agreement program) are responsible for conducting public health assessments, for communicating the findings of their evaluations to the public, and for involving the community and responding to customs health concerns. The process may crave the coordination and cooperative efforts of ATSDR'south Division of Wellness Assessment and Consultation (DHAC) with other offices and divisions within ATSDR; other local/county, land, and federal regime agencies; tribes; and the community.

Early in the process, the team leader—more often than not you, the health assessor—establishes a team composed of individuals who contribute to the site-specific technical and communication needs of the site. Experience has shown that a team arroyo is very effective, especially at more complex sites. The mix of the team will depend on the nature and complexity of site problems and may change over the grade of the cess equally more data becomes available. Team members may include scientists (e.g., engineers, ecology or public health scientists, geologists, toxicologists, epidemiologists, health physicists), advice specialists, health educators, and/or medical professionals.

Those who support the assessment will vary from site to site. Regional representatives from the agency's Division of Regional Operations should exist included on site teams. The regional representative is a vital link between ATSDR; federal, state, and tribal partners; and the community. For many sites, your team may require a health communication specialist to ensure that advisable customs involvement and outreach mechanisms are established. Where tribal problems are identified or if help is needed in identifying tribal concerns, ATSDR'south Role of Tribal Affairs (OTA) will exist contacted (see Appendix A for policies governing ATSDR'due south relationship with tribal governments and Section iv.2.3 for further information well-nigh OTA). When environmental justice concerns exist, the National Center for Environmental Health (NCEH)/ATSDR'south Office of Managing director/Environmental Justice may become involved (see Section iv.two.iv). In addition, activities and recommendations throughout the public health cess procedure may require input and back up from other NCEH/ATSDR offices or divisions, such every bit the Part of Communication, Division of Health Education and Promotion, the Division of Health Studies, and the Partitioning of Toxicology. For some sites, ATSDR'south Washington, D.C. office may need to exist involved or kept informed. For ATSDR partners, many of the tasks often undertaken by divide divisions within ATSDR will exist conducted past the health assessor and local team members.

Effigy 2-1 illustrates the individuals and groups that may play a role in the public health assessment process.

2.4 What Is the Office of the Site Community?

Communities often play an important role in the public health assessment process. For a particular site, the customs by and large consists of people who live and work at or around the site. The community may include, for example, residents, site or facility personnel, members of local activity groups, local officials, tribal members, health professionals, and local media.

Community members are a resource for and a principal audience and beneficiaries of the public wellness assessment process. They can provide important information and ideas that may bear witness valuable input to the public health assessment. For case, they can often supply site-specific information that might otherwise not be documented. As yous conduct your assessment, community members may also want to know what the process involves, what they tin and cannot wait, what conclusions you lot achieve, and in general how ATSDR and the public wellness assessment process can help address their concerns. The relationship you build with the community through your public involvement and communication activities volition influence how much community members trust you and thus, ultimately, how they react to your public health messages and recommendations. For all these reasons, constructive involvement of and advice with the community is of import throughout the public health assessment process.

Since 1990, ATSDR has embraced the philosophy of continuous comeback of and increased attention to its community interest and wellness didactics efforts, which include identifying and reaching out to the concerned public; informing and educating; promoting interaction and dialogue; involving communities in planning, implementing, and controlling; providing opportunity for comments and input; and collaborating in developing meaningful partnerships.

Affiliate 4 provides guidance on how to plan for and conduct community involvement activities. By reading Chapter iv earlier the subsequent capacity, which provide guidance on the technical aspects of the public health assessment process, yous volition be improve able to incorporate public involvement and basic communication principles into all the activities y'all perform at a site.

two.5 How Is a Public Wellness Assessment Conducted?

The public wellness assessment procedure involves multiple steps, merely consists of two primary technical components—the exposure evaluation and the health effects evaluation. These two components atomic number 82 to making conclusions and recommendations and identifying specific and appropriate public health actions to forestall harmful exposures.

Integral to the entire procedure are effective fact finding and thorough scientific evaluation. Identifying and understanding the public wellness concerns of the site community—as well every bit involving and effectively communicating with the public—is another important component of the process. Skillful communication among ATSDR, other agencies, and the community is essential throughout the public health cess process.

The exposure evaluation involves studying the environmental data and agreement if and under what atmospheric condition people might contact contaminated media (e.m., water, soil, air, food chain [biota]). The data compiled in the exposure evaluation is used to support the health furnishings evaluation, which includes a screening component, a more detailed analysis of site-specific exposure considerations and of the substance-specific information obtained from the toxicologic and epidemiologic literature. An additional consideration, although not always available, is an evaluation of health outcome data for the customs of interest.

The specific steps in the procedure are summarized below and detailed in Capacity 3 through 9. Effigy 2-2 maps out the overall public health assessment procedure.

The evaluation is an iterative, dynamic process that considers available data from varying perspectives. The process is not always linear. In reality, many activities may occur simultaneously and/or require repeated efforts. Further, because sites are unlike, not every attribute of the public wellness assessment procedure described in this manual will use to all sites.

Some other very important point to remember about the process is that public health assessment teams should not wait to complete the unabridged step-past-footstep cess process earlier recommending an action to address a public health gamble. Instead, the squad should immediately focus its efforts on the public wellness hazard, confer with all stakeholders, and coordinate and implement appropriate actions to minimize exposures and protect public wellness.

The public health assessment process oftentimes requires the consideration of multiple information sets. Information technology is the wellness assessor'southward job to sort through this information and identify key data that will help determine whether people are being exposed to site-related contaminants at sufficient levels to result in adverse wellness effects. Equally y'all exercise so, you should identify information gaps and limitations, such every bit the need for further environmental sampling.

ii.5.1 Getting Started

Once assigned a site to evaluate, your first step is to found an overall agreement of the site and brainstorm to identify the well-nigh pertinent bug. You demand to quickly proceeds some baseline information about your site. Once you start to build an information base, you lot can start developing a strategy for conducting the public health assessment.

To help ensure a consistent arroyo across sites, the following steps should exist followed:

• Initiate site scoping. Perform an initial review of site files and full general sources of site data (east.g., summary reports, petition letters, media reports, EPA summaries on the Web). Identify any past ATSDR activities or activities conducted by ATSDR's partners. The ATSDR regional staff are an important contact for site information at this initial footstep. Initial scoping efforts will help you lot identify the type of ecology, exposure, and community health business information you may need to pursue. Identify and communicate with site contacts (e.1000., state agencies, tribal governments, facility representatives) to acquire virtually site ecology weather condition, the condition of site investigations, and the involvement of other stakeholders. During site scoping you will also make up one's mind when to bear the site visit. The site visit should be viewed equally a prime opportunity for meeting with the local community and gathering pertinent site data, in improver to providing you with first-manus noesis of current site conditions.
• Define roles and responsibilities of team members (internal and external). Place core squad members as early every bit possible. Every bit described in Section two.3, the mix of the team and each member's responsibility will depend on site issues. Establishing the squad early will foster ameliorate communications throughout the public health assessment process.
• Plant communication mechanisms (internal and external). Establish government agency, tribal, site, community, and other stakeholder contacts early in the process. Develop a schedule for team meetings, start because how to present the findings of your assessment, and develop wellness communication strategies. This requires agreement the information needs of your audience. Adequate communication with the local customs is an important part of the public health assessment process. Therefore, a strategy to develop and maintain communication with the customs should be developed early in the process.
• Develop a site strategy. As y'all move forwards, be mindful of the diverse steps in the public wellness cess process (see Effigy 2-2) and develop a strategy for completing these tasks. Each of these steps are summarized in the sections beneath and detailed in subsequent capacity of this manual. During the planning stages, you volition need to brainstorm to place the tools and resources that might be needed to evaluate the site, communicate your findings, and implement public wellness actions. Conscientious planning will provide a strong foundation for all subsequent activities.Based on information obtained during site scoping, develop an approach that focuses on the well-nigh pertinent public wellness issues. Identify site priorities both in terms of potential exposures and community health concerns. Establish aggressive but realistic time lines for the various components of your site-specific evaluation. Annotation that your strategy may change over time. Remember that the public health assessment process is iterative. The information you lot proceeds equally you carry your public wellness assessment may generate new information and perspectives that may prompt you to revise your strategy.

two.five.2 Collecting Needed Information

Throughout the public health assessment procedure, you and other site team members will collect information well-nigh the site. Figure two-3 illustrates the type of information that supports the assessment.

Information gathering mostly occurs throughout the public health assessment process, just the initial collection of information is typically the most intensive. In the early on phases of information collection, described in detail in Affiliate iii, you are building the foundation of site-specific data and data for the remainder of your activities at the site. Equally mentioned to a higher place, you will be collecting information nigh community health concerns, exposure pathways, and environmental contamination, too as identifying whatsoever site-specific wellness consequence data. Data sources typically include interviews (in-person or via phone); site-specific investigation reports prepared by EPA, other federal agencies, and state, tribal, and local ecology and health departments; and site visits.

Gathering pertinent site data requires a series of iterative steps, including gaining a basic understanding of the site, identifying data needs and sources, conducting a site visit, communicating with customs members and other stakeholders, critically reviewing site documentation, identifying data gaps, and compiling and organizing relevant information to support the cess.

2.5.3 Exposure Evaluation: Evaluating Environmental Contagion Data

Disquisitional to the public health cess process is evaluating exposures. I component of this evaluation is understanding the nature and extent of environmental contamination at and effectually a site. During this pace, described in detail in Chapter 5, you will evaluate the environmental contamination data obtained to determine what contaminants people may be exposed to and in what concentrations. Equally part of this evaluation, you will be assessing the quality and representativeness of bachelor environmental monitoring data and determining exposure signal concentrations. This is an important way to ensure that any public health conclusions and recommendations for the site are based on appropriate and reliable data. In some cases, further environmental sampling may be recommended to fill a critical data gap. While sampling data are preferred for public health assessments, mathematical modeling techniques are sometimes used to estimate environmental concentrations either temporally or spatially (run into Section v.2). Evaluation of environmental contagion data typically proceeds simultaneously with the exposure pathway evaluation.

2.5.4 Exposure Evaluation: Identifying Exposure Pathways

During the exposure pathway evaluation, described in item in Chapter 6, you will evaluate who may be or has been exposed to site contaminants, for how long, and under what weather. You will consider past, current, and potential hereafter exposure atmospheric condition. This involves identifying and studying the post-obit five components of a "completed" exposure pathway:

• A source of contamination.
• A release mechanism into water, soil, air, food chain (biota) or transfer betwixt media (i.east., the fate and transport of environmental contamination).
• An exposure indicate or area (e.g., drinking water well, residential m).
• An exposure road (eastward.g., ingestion, dermal contact, inhalation).
• A potentially exposed population (e.g., residents, children, workers).

The overall purpose of this evaluation is to sympathise how people might go exposed to site contaminants (e.g., via drinking affected water or by coming in contact with contaminated soils) and to place and characterize the size and susceptibility of the potentially exposed populations. If all of the elements described above are identified, a completed pathway exists. If one or more components are missing or uncertain, a potential exposure pathway may exist. For completed or potential exposure pathways, y'all will evaluate the magnitude, frequency, and duration of exposures.

As yous evaluate exposure pathways, you should constantly remind yourself: If no completed or potentially completed exposure pathways are identified, no public health hazards will exist. If, every bit a result of your evaluation, you conclude there are no exposure pathways, then you will not need to perform farther scientific evaluation. You volition, all the same, need to explicate your rationale for excluding each exposure pathway you deem incomplete and should communicate the conclusion of an incomplete pathway to the public at the earliest point possible. Boosted community concerns non related to potential exposure pathways may exist addressed in the community concerns section of the written public health assessment or the public health action program (see Section 2.vii).

When complete ecology or biologic data are lacking for a site, you may determine that an exposure investigation is needed to amend assess possible impacts to public health. These exposure investigations, often conducted by ATSDR or cooperative agreement partners, may include environmental sampling, measurements of current human exposure (e.m., biologic monitoring), and/or using a variety of fate and ship models linked with geographic information systems to estimate by (dose reconstruction) or predict future exposure concentrations. The results of an exposure investigation are used to support the public wellness assessment process.

2.5.five Wellness Effects Evaluation: Conducting Screening Analyses

Screening is a showtime step in understanding whether the detected concentrations to which people may be exposed are harmful. The screening analysis, described in detail in Chapter 7, is a adequately standard procedure ATSDR has developed to aid health assessors sort through the often large volumes of environmental information for a site. Information technology enables yous to safely rule out substances that are non at levels of health concern and to identify substances and pathways that need to exist examined more than closely. For completed or potential exposure pathways identified in the exposure pathway evaluation, the screening analysis may involve:

• Comparing media concentrations at points of exposure to health-based "screening" values (based on protective default exposure assumptions).
• Estimating exposure doses based on site-specific exposure atmospheric condition that you lot volition then compare with health-based guidelines.

ii.5.half-dozen Health Effects Evaluation: Conducting In-Depth Analyses

For those pathways and substances that y'all identify in the screening analysis every bit requiring more careful consideration, you and site team members will examine a host of factors to assistance determine whether site-specific exposures are likely to event in illness and whether a public health response is needed. In this integrated arroyo, described in detail in Chapter eight, exposures are studied in conjunction with substance-specific toxicologic, medical, and epidemiologic data.

Through this in-depth analysis, you will be answering the following question: Based on bachelor exposure, toxicologic, epidemiologic, medical, and site-specific health outcome data, are agin health effects likely in the community? You will exist considering not only the potential wellness impacts on the general customs, merely also the impact of site-specific exposures to any uniquely vulnerable populations (e.m., children, the elderly, women of changeable age, fetuses, and lactating mothers) in the community.

two.v.7 Formulating Conclusions and Recommendations and Developing a Public Health Activity Program

Upon completing the exposure and wellness effects evaluations, yous will describe conclusions regarding the degree of hazard posed past a site (described in particular in Chapter ix)—that is, you lot will conclude either that the site does not pose a public health hazard, that the site poses a public health run a risk, or that insufficient data are available to determine whether any public health hazards exist. The process as well involves assigning a "hazard decision category" for the site or for an individual exposure pathway. Later on drawing conclusions (which occurs throughout the public wellness assessment process), you will develop recommendations for actions, if whatever, to prevent harmful exposures, obtain more than data, or conduct other public health actions. These actions will be detailed in a Public Health Action Program, which will ultimately be part of the public health assessment document (or mayhap public health consultations) you develop for the site, as described in Section 2.6. Notation that some public wellness actions may be recommended earlier in the procedure (encounter Section 2.6).

ii.half-dozen What Products and Actions Result From the Public Wellness Assessment Process?

2.6.1 Products

You may develop diverse materials during the public health assessment process to communicate information about the assessment. For case, the team may develop outreach materials, as described in Chapter iv , to communicate the status and findings of your assessment to the site customs. If y'all identify imminent health hazards during the assessment process, you may issue a health advisory that alerts the public and appropriate officials to the being of a public health threat and identifies measures/actions that should be taken immediately to eliminate the wellness threat (see Affiliate nine for more than information about wellness advisories). Whether and when to produce these materials or advisories and in what format is upwards to the judgment of the site squad and their direction.

At the terminate of the assessment procedure, you lot volition prepare a report that summarizes your approach, results, conclusions, and recommendations. This written report may exist either a public health assessment document (PHA) or a public wellness consultation (PHC).

• A PHA may be prepared to accost various exposure situations and/or customs wellness concerns. It may accost multiple-chemical, multiple-pathway exposures or it may address a single exposure pathway. Regardless of the focus of the PHA, all of the CERCLA-required elements must be included in the PHA.
• A PHC is generally prepared to describe the findings of an assessment that focuses on one particular public health question (e.grand., a specific exposure pathway, substance, health status, or technical interpretation). For instance: Will community members be harmed by drinking water from private wells around the site? Is a proposed site-specific sampling programme adequate to collect data to apply in a public health evaluation? Such assessments oftentimes are more time critical, necessitating a more rapid and therefore express response than assessments that outcome in a PHA. While some PHCs include a presentation of all the elements required in the PHA (i.e., a comprehensive exposure pathway and wellness effects evaluation), discussions are often express to answering the question at hand.

A PHA is generally produced for all NPL sites. For petitioned sites, you may produce either a PHA or a PHC depending on site-specific problems and information needs. Sometimes, an assessment of a single issue at a petitioned site may evolve into a more multifaceted cess that results in a PHA. Regardless of the document prepared, the overall assessment process, as described in this manual, is generally the same.

2.6.two Public Health Actions

As stated earlier, during the public health assessment process, you will non only evaluate whether a site poses a public health hazard, simply also place public health actions. Actions may exist recommended at any advisable signal in the assessment process. Some recommended deportment may be initiated before the completion of the PHA, such equally certain health education activities or efforts to obtain additional exposure data. Other actions may begin during the cess process but terminate later the release of the PHA for a site (e.g., health studies or research). Community involvement continues to exist of import every bit you identify and communicate public health deportment.

Public wellness actions vary from site to site and may include:

• Actions to reduce exposures. If current harmful exposures are identified, removal or clean-upward deportment may exist recommended. This will more often than not involve working with the appropriate federal, state, or tribal agencies.
• Exposure investigations. As function of your exposure evaluation, you may determine that critical exposure information are missing. In such cases, the site team may recommend ecology or biologic sampling to better define the extent, if any, of harmful exposures. (meet Department 6.7)
• Health teaching. Throughout the public health cess process, you may identify the need for education within a customs. For instance, ATSDR'due south Division of Health Didactics and Promotion or the appropriate local health department may educate health professionals nigh special diagnostic techniques for possible site-related illnesses identified during the public health cess procedure.
• Health services. Site conditions may identify the need for certain community health interventions, such as medical monitoring or psychological stress counseling. Referrals may be made to health care providers (due east.g., community wellness centers or local health departments) when health services are needed that may improve the overall wellness of the community. ATSDR does not have the legal authority to provide medical intendance or treatment to people who take been exposed to chancy substances, even if the exposure has made them ill. ATSDR works with health care agencies to address customs wellness care needs.
• Health studies/health surveillance. Public wellness assessments are not epidemiologic or health studies. Notwithstanding, during the public health assessment procedure, you may identify an exposed population for whom a site-specific epidemiologic or health report should be considered (e.m., disease- and symptom-prevalence studies, cluster investigations). An epidemiologist should be involved with evaluating the need and feasibility of whatsoever such report. ATSDR's Partition of Health Studies or comparable local agency should be involved in designing, implementing, and interpreting any such study.
• Inquiry. Knowledge gaps that y'all identify concerning the toxicity of substances identified at a site or release under review may trigger substance-specific research, computational toxicology, or expanded efforts in developing ATSDR toxicological profiles.

2.vii What Is the Format for Public Health Assessment Documents?

General PHA Format

• Primary sections
  • Summary
  • Purpose and health issues
  • Groundwork
  • Discussion ^one
  • Community health concerns
  • Conclusions
  • Recommendations
  • Public health action plan
• Preparers of report
• References
• Tables
• Figures
• Appendices
  • Additional background materials
  • More in-depth technical discussions
  • Glossary (including conclusion category summary)
  • Response to public comments

_____________

¹A separate give-and-take on kid wellness considerations is required in all PHAs.

This department describes the content and format guidelines for PHAs and PHCs. Communicating the findings of your cess in an organized, clear, and concise way is equal in importance to conducting a scientifically sound evaluation. Every bit you prepare a public health assessment document, you will make many choices nigh how to organize textile within each section, how much detail to provide, whether to apply a question-and-reply format in various sections, and and then on.

While ATSDR has developed the minimum requirements presented below to ensure consistency and abyss, the agency encourages wellness assessors to remain flexible while fulfilling these requirements. You should employ the well-nigh appropriate site-specific approach, based on the knowledge, expectations, and information needs of your audition. The suggested format provides a framework for documenting the findings of the public wellness assessment. Subsequent chapters provide more detail on the blazon of information that you lot may need to consider and include in each section of the document.

Generally, PHAs include the sections and appendices described below. Additional sections may be included equally you judge appropriate if the data may be helpful in communicating the findings. The main trunk of the document should exist long enough to fully address pertinent issues. Narratives should be concise and relevant to those bug.

The master sections of a PHA are:

• Summary. In this section, you lot will summarize the most important conclusions and recommendations of the PHA. This department should exist every bit simple, clear, and concise as possible, since it volition be one of the well-nigh frequently read sections of the certificate. As appropriate, you may include a cursory summary of previous public wellness evaluations of the site and/or a cursory caption of the planned futurity public health evaluations of the site. Exercise not include whatever technical data, conclusions, or recommendations that are not addressed in the master torso of the certificate.
• Purpose and Health Problems. In this section, you should explicate what the PHA will and volition not discuss. This department focuses the discussion for the balance of the PHA by posing the question(s) that volition be addressed in the PHA. This section may include a brief overview of the health concerns voiced by the site customs, with reference to a later section in the PHA that addresses those concerns.
• Background. This section should comprise all pertinent "factual" data and data needed to frame or lead into the Word section. Typically in this section, you lot will present the site description, site history, demographics, land utilize, and natural resources employ equally information technology relates to the issues presented in the Purpose and Health Issues section. Practice non include whatsoever data not directly relevant to the issue(south) existence discussed in the PHA (though you lot may identify information technology in an appendix if you lot approximate it important to brand the data available to the reader).
• Discussion. In this department, report the findings of your exposure and health effects evaluations. Describe what is known (and not known) about environmental exposures to site-specific contaminants. Clearly describe site-specific exposure conditions (or how people may contact site contaminants). Then discuss how site-specific exposure levels compare with health-based screening levels; if screening levels are exceeded, and so explain how site-specific exposure levels (and atmospheric condition) compare to levels shown to cause damage in relevant scientific studies. Describe how the integration of pertinent exposure and health furnishings data leads you to your overall conclusion—that is, explicate/state whether site-specific weather condition are probable to result in adverse health effects. This give-and-take should provide back up for and help to justify the conclusions that you will present in the subsequent Conclusions department. Yous must also include a distinct subsection within the Discussion section that discusses child health issues. You tin use different formats for the Discussion section depending on the site. In some cases, you lot may wish to discuss public wellness bug on an exposure pathway-by-pathway basis. In others, a question-and-respond format might work improve. Yous may provide varying levels of technical detail as appropriate to the site, but, you should always strive to continue the text articulate and simple and use appendices equally appropriate to provide more than detailed technical discussions. Likewise, you should use tables, figures, and maps whenever possible to facilitate the agreement of written text.
• Community Health Concerns. In this section, nowadays answers to any health questions the public may have about the site. A question-and-answer format is often most advisable. You can include the Community Health Concerns section either equally a divide department in the PHA or as a subsection of the Discussion section, depending on which is most appropriate to the optimal logic and flow of the document.
• Conclusions. In this section, briefly nowadays the conclusions of the public health cess process. If yous take reached more one conclusion, yous may want to nowadays your conclusions as a listing, starting with the decision(due south) that direct address the issues presented in the Purpose and Health Bug section. Include a argument that assigns a hazard determination category (come across Section 2.5.7 and Affiliate ix) to the site, time period (eastward.g., past, current, or future), or exposure pathway, as appropriate. While y'all should not reiterate large portions of previous sections, you must support each determination with a cursory merely adequate discussion of available data and information. This summation should follow logically from the relevant portions of the Give-and-take department.
• Recommendations. In this section, you will describe recommendations that the site team has developed based on the conclusions reached well-nigh the site, every bit described in the Conclusions section. More often than not, the almost constructive fashion to communicate recommendations is to organize them as a list and to brainstorm each recommendation with an activity discussion (e.yard., provide, monitor, restrict, obtain, inform, etc.). Once more, ATSDR makes public health recommendations; it does not make specific adventure management decisions. Ideally, advice amongst ATSDR and parties responsible for implementing the recommendations volition have been ongoing throughout the public wellness cess process. Such communication volition help place actions needed to implement the recommendations.
• Public Wellness Action Plan. Every PHA must include a public health action plan (PHAP) indicating the specific actions that are warranted. The PHAP should present actions that have been completed as well as those that are ongoing or planned. Give-and-take with the entities (e.1000., other agencies) who will ultimately be responsible for conducting specific actions is required ahead of time.

In addition to the main text of the document you lot must include the preparers of the report, references, and various appendices. While your text should be written equally clearly and concisely as possible when relaying the findings of the cess, the use of various technical terms will likely be unavoidable. You should, therefore, include a glossary of terms in all PHAs. The "plain language" glossary adult by ATSDR should be used as a starting point (run across Appendix B). As mentioned, yous will demand to assign a conclusion category to your site and the exposure situations evaluated. A summary of the five ATSDR conclusion categories must be included in all PHAs, either as part of your glossary or as a stand-alone list.

For the final version of the PHA, y'all will accept gathered public comments. An appendix will be dedicated to listing these comments and explain how the PHA responds them. The format and content of the appendix will depend on the number and nature of the comments yous have received; the responses will be based on the judgment of the site squad. For example, if comments are few in number or correspond unique problems, you volition likely present each comment more or less verbatim. In other cases, you may choose to summarize like comments or edit comments to more than succinctly present expressed concerns or questions. When doing then, be careful not to eliminate specific points made or question asked past the commenters. To facilitate your response and nowadays information technology effectively, group comments past major theme or by section of the PHA (e.one thousand., site history, groundwater issues, conclusions). In your responses, focus on addressing technical issues raised by commenters, explaining how and why ATSDR took a sure arroyo or drew a particular decision. If the comment points out an error or introduces new information, acknowledge whatsoever fault, review any new information, and explain how ATSDR may have revised its assessment in light of that data. (Department 4.7.one.3 in Chapter 4 provides boosted guidance in responding to public comments.)

Like the PHA, the PHC has certain minimum requirements as ready forth by agency policy (May 27, 1995). The PHC should include, at a minimum, the following:

• Summary^(ane)
• Background/Statement of Issues
• Discussion
• Conclusions
• Recommendations

• PHAP, if applicable
• Response to Public Comments, if applicative
• References
• Appendices (as required)

In preparing PHAs and PHCs, your text should exist written in as clear and understandable a mode every bit possible. The box below contains a few tips for constructive communication. Many of these tips are elaborated upon in subsequent chapters.

• Tell the story.
• Consider your audience(southward).
• Be concise (do not include anything that does not add to the story).
• Use "plainly" language where possible to describe the evaluation and conclusions.
• Apply the active voice.
• Conspicuously communicate the following concepts:
  • Public health assessments are exposure-driven. Remember, exposure must occur to allow the potential for agin wellness furnishings.
  • Simply existence exposed to a hazardous substance does not brand information technology a hazard—the magnitude, frequency, timing of exposure (e.g. pregnant female, fetal development), elapsing of the exposure, and the toxicity characteristics of individual substances affect the degree of adventure, if any.
• Think perspective. Put available environmental and health effects data into meaningful perspective for the community.
• The linguistic communication should non unnecessarily warning the reader, nor should the wellness assessor downplay concerns/exposures.
• Write a simple summary that will capture key points and give lesser lines.
• Keep conclusions focused and be certain that recommendations parallel the conclusions.
• If data is unavailable and, every bit a effect, no conclusions can be drawn, but state this fact.
• Reference all statements of fact—go far clear what are judgments and opinions.

ⁱA summary is optional in a PHC, but recommended when the PHC is lengthy or technically complex.

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Source: https://www.atsdr.cdc.gov/hac/phamanual/ch2.html

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