INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 1

Company name:

Company address:

Responding official name:

Responding official title:

Certifying official name:

Certifying official title:

Certifying official contact information: 

Email:

Telephone:

I certify under penalty of law that this document and all attachments were prepared under my direction or 

supervision in accordance with a system designed to assure that qualified personnel properly gather and 

evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, 

or those persons directly responsible for gathering the information, I certify that the information submitted 

is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are 

significant penalties for submitting false information, including the possibility of fine and imprisonment for 

knowing violations.

Certifying official signature Date

___________________________________________________________________________________

1.a. Manufacture, import, or export of products

Did your company manufacture, import, or export a product (or products) containing mercury or 

mercury compounds in the years 2010, 2013, and/or 2016?

No; if possible, describe why (e.g., permanently ceased such activity)

Yes

1.b. Manufacturing processes

Did your company use mercury or mercury compounds in a manufacturing process (or processes) (e.g., 

as commercial chemical products, including catalysts, preservatives, reactants, reagents) in the years 

2010, 2013, and/or 2016? 

No; if possible, describe why (e.g., permanently ceased such activity)

Yes

IF YOU SELECTED “NO” IN RESPONSE TO QUESTIONS 1.A. AND 1.B., THEN DO NOT COMPLETE ANY

ADDITIONAL SECTIONS OF THIS QUESTIONNAIRE.

IF YOU SELECTED “YES” IN RESPONSE TO QUESTIONS 1.A. AND/OR 1.B., THEN PROCEED TO SECTION 2.
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Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 2

In the table below, please check the box for each product category for which your company 

manufactured, imported, or exported a product or products in the years 2010, 2013, and/or 2016. If you 

manufactured, imported or exported a mercury-containing product that does not fall within the listed 

product categories, then check the box for “Miscellaneous mercury-added products.”

Categories of Mercury-added Products

If you checked a 

box at left, then 

proceed to:

Batteries Section #3

Cosmetics (including skin lightening soaps and creams) Section #4

Dental amalgam Section #5

Formulated products (e.g., commercial chemical products, including catalysts, 

preservatives, reactants, reagents)

Section #6

Lighting, lamps, bulbs (including neon lighting and backlighting displays) Section #7

Pesticides, biocides, topical antiseptics (including paint) Section #8

Pumps Section #9

Measuring instruments (e.g., barometers, thermometers) Section #10

Switches, relays, sensors, valves (including thermostats) Section #11

Miscellaneous mercury-added products (e.g., a product containing mercury not 

otherwise described in the above categories)

Section #12

Products derived from the use of mercury or mercury compounds in a 

manufacturing process

Section #13

Certain Uses Within Categories of Mercury-added Products:

Please check each of the boxes below that apply to product category(ies) selected above, if the 

manufactured, imported, or exported product(s):

Is (are) essential for civil protection or military uses;

Is (are) used only for research, calibration of instruments, as a reference standard, or as a vaccine; or

Contain(s) only trace contaminants of mercury.
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Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 3: Batteries

Did your company manufacture batteries that contain mercury or mercury compounds in 2010, 2013, or 

2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

battery per year(s): (Use either metric or U.S. customary units)

Button cell, silver 2010 2013 2016 

Button cell, zinc-air 2010 2013 2016 

Button cell, alkaline 2010 2013 2016 

Stacked button cell batteries 2010 2013 2016 

Manganese oxide 2010 2013 2016 

Silver oxide 2010 2013 2016 

Mercuric oxide 2010 2013 2016 

Button cell, mercuric oxide 2010 2013 2016 

Button cell, zinc carbon 2010 2013 2016 

Large methylmercury batteries 2010 2013 2016 

Other batteries 2010 2013 2016 

If “other,” then provide a general description of the batteries:

Did your company manufacture any button cell batteries with mercury content of 2% or greater?

No; please proceed to question (2) of this section.

Yes

If yes, then provide the approximate percentage of button cell batteries provided for question (1)a. of 

this section in each of the following years:

2010 __________

2013 __________

2016 __________

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of batteries manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

Mercury or mercury compounds used by your company to manufacture batteries in each of the 

following years: (Use either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Did your company import mercury or mercury compounds to be used in the production of batteries 

manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture batteries in each of the following years: (Use either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import batteries containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported battery per year(s): (Use either metric or U.S. customary units)

Button cell, silver 2010 2013 2016 

Button cell, zinc-air 2010 2013 2016 

Button cell, alkaline 2010 2013 2016 

Stacked button cell batteries 2010 2013 2016 

Manganese oxide 2010 2013 2016 

Silver oxide 2010 2013 2016 

Mercuric oxide 2010 2013 2016 

Button cell, mercuric oxide 2010 2013 2016 

Button cell, zinc carbon 2010 2013 2016 

Large methylmercury batteries 2010 2013 2016 

Other batteries 2010 2013 2016 

If “other,” then provide a general description of the batteries:

Did your company import any button cell batteries with mercury content of 2% or greater?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the approximate percentage of button cell batteries reported for question (4)a. of this 

section in each of the following years:

2010 __________

2013 __________
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

2016 __________

Did your company export batteries containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported battery per year(s): (Use either metric or U.S. customary units)

Button cell, silver 2010 2013 2016 

Button cell, zinc-air 2010 2013 2016 

Button cell, alkaline 2010 2013 2016 

Stacked button cell batteries 2010 2013 2016 

Manganese oxide 2010 2013 2016 

Silver oxide 2010 2013 2016 

Mercuric oxide 2010 2013 2016 

Button cell, mercuric oxide 2010 2013 2016 

Button cell, zinc carbon 2010 2013 2016 

Large methylmercury batteries 2010 2013 2016 

Other batteries 2010 2013 2016 

If “other,” then provide a general description of the batteries:

Did your company export any button cell batteries with mercury content of 2% or greater?

No; please proceed to question (6) of this section; 

Yes

If yes, then provide the approximate percentage of button cell batteries reported for question (5)a. of this 

section in each of the following years:

2010 __________

2013 __________

2016 __________

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S) 

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 4: Cosmetics

Did your company manufacture cosmetics that contain mercury or mercury compounds in 2010, 2013, 

or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

cosmetics per year(s): (Use either metric or U.S. customary units)

Skin care products (creams, soaps, lotions) 2010 2013 2016 

Other cosmetics 2010 2013 2016 

If “other,” then provide a general description of the cosmetics:

Did your company manufacture any cosmetics with mercury content of greater than 1 ppm?

No; please proceed to question (2) of this section.

Yes

If yes, then provide the approximate percentage of the number provided for question (1)a. of this section 

in each of the following years:

2010 __________

2013 __________

2016 __________

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of cosmetics manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture cosmetics in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of cosmetics

manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture cosmetics in each of the following years: (Use either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import cosmetics containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported cosmetics per year(s): (Use either metric or U.S. customary units)

Skin care products (creams, soaps, lotions) 2010 2013 2016 

Other cosmetics 2010 2013 2016 

If “other,” then provide a general description of the cosmetics:

Did your company import any cosmetics with mercury content of greater than 1 ppm?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the approximate percentage of cosmetics reported for question (4)a. of this section in 

each of the following years:

2010 __________

2013 __________

2016 __________

Did your company export cosmetics containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported cosmetics per year(s): (Use either metric or U.S. customary units)

Skin care products (creams, soaps, lotions) 2010 2013 2016 

Other cosmetics 2010 2013 2016 

If “other,” then provide a general description of the cosmetics:
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Did your company export any cosmetics with mercury content of greater than 1 ppm?

No; please proceed to question (6) of this section; 

Yes

If yes, then provide the approximate percentage of cosmetics reported for question (5)a. of this section in 

each of the following years:

2010 __________

2013 __________

2016 __________

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S) 

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 5: Dental Amalgam

Did your company manufacture dental cements and fillings that contain mercury or mercury compounds 

in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

dental cements and fillings per year(s): (Use either metric or U.S. customary units)

Dental cements and fillings 2010 2013 2016 

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of dental cements and fillings manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture dental cements and fillings in each of the following years: (Use either 

metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of dental 

cements and fillings manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture dental cements and fillings in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________

2013 __________

2016 __________

Did your company import dental cements and fillings containing mercury or mercury compounds in 

2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported dental cements and fillings per year(s): (Use either metric or U.S. customary units)

Dental cements and fillings 2010 2013 2016 

Did your company export dental cements and fillings containing mercury or mercury compounds in 

2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported dental cements and fillings per year(s): (Use either metric or U.S. customary units)

Dental cements and fillings 2010 2013 2016 

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S) 

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 6: Formulated Products

Did your company manufacture formulated products (e.g., commercial chemical products, including 

catalysts, preservatives, reactants, reagents) that contain mercury or mercury compounds in 2010, 2013, 

or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

formulated products per year(s): (Use either metric or U.S. customary units)

Catalysts 2010 2013 2016 

Preservatives 2010 2013 2016

Reactants 2010 2013 2016 

Reagents 2010 2013 2016 

Other formulated products 2010 2013 2016 

If “other,” then provide a general description of the formulated products:

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of formulated products manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture formulated products in each of the following years: (Use either metric or 

U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of formulated 

products manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture formulated products in each of the following years: (Use either metric or U.S. customary

units)

2010 __________

2013 __________

2016 __________
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Did your company import formulated products containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported formulated products per year(s): (Use either metric or U.S. customary units)

Catalysts 2010 2013 2016 

Preservatives 2010 2013 2016 

Reactants 2010 2013 2016 

Reagents 2010 2013 2016 

Other formulated products 2010 2013 2016 

If “other,” then provide a general description of the formulated products:

Did your company export formulated products containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported formulated products per year(s): (Use either metric or U.S. customary units)

Catalysts 2010 2013 2016 

Preservatives 2010 2013 2016 

Reactants 2010 2013 2016 

Reagents 2010 2013 2016 

Other formulated products 2010 2013 2016 

If “other,” then provide a general description of the formulated products:

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 7: Lighting, Lamps, Bulbs

Did your company manufacture lighting, lamps, or bulbs (including neon lighting and backlighting 

displays) that contain mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

lighting, lamps, or bulbs per year(s): (Use either metric or U.S. customary units)

Linear fluorescent 2010 2013 2016 

Compact fluorescent 2010 2013 2016 

Cold cathode fluorescent 2010 2013 2016 

External electrode fluorescent 2010 2013 2016 

Mercury high pressure vapor 2010 2013 2016 

High intensity discharge 2010 2013 2016 

Mercury short arc 2010 2013 2016 

Neon 2010 2013 2016 

Other lighting, lamps, bulbs 2010 2013 2016 

If “other,” then provide a general description of the lighting, lamps, or bulbs:

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of lighting, lamps, or bulbs manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture lighting, lamps, or bulbs in each of the following years: (Use either metric 

or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of lighting, 

lamps, or bulbs manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture lighting, lamps, or bulbs in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

2013 __________

2016 __________

Did your company import lighting, lamps, or bulbs containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported lighting, lamps, or bulbs per year(s): (Use either metric or U.S. customary units)

Linear fluorescent 2010 2013 2016 

Compact fluorescent 2010 2013 2016 

Cold cathode fluorescent 2010 2013 2016 

External electrode fluorescent 2010 2013 2016 

Mercury high pressure vapor 2010 2013 2016 

High intensity discharge 2010 2013 2016 

Mercury short arc 2010 2013 2016 

Neon 2010 2013 2016 

Other lighting, lamps, bulbs 2010 2013 2016 

If “other,” then provide a general description of the lighting, lamps, or bulbs:

Did your company export lighting, lamps, or bulbs containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported lighting, lamps, or bulbs per year(s): (Use either metric or U.S. customary units)

Linear fluorescent 2010 2013 2016 

Compact fluorescent 2010 2013 2016 

Cold cathode fluorescent 2010 2013 2016 

External electrode fluorescent 2010 2013 2016 

Mercury high pressure vapor 2010 2013 2016 

High intensity discharge 2010 2013 2016 

Mercury short arc 2010 2013 2016 

Neon 2010 2013 2016 

Other lighting, lamps, bulbs 2010 2013 2016 

If “other,” then provide a general description of the lighting, lamps, or bulbs:
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 8: Pesticides, Biocides, Topical Antiseptics (including Paint)

Did your company manufacture pesticides, biocides, or topical antiseptics (including paint) that contain 

mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

pesticides, biocides, or topical antiseptics per year(s): (Use either metric or U.S. customary units)

Agricultural applications 2010 2013 2016 

Interior/exterior paints 2010 2013 2016 

Other pesticides, biocides, and topical antiseptics 2010 2013 2016 

If “other,” then provide a general description of the pesticides, biocides, or topical antiseptics:

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of pesticides, biocides, or topical antiseptics manufactured by your company in 2010, 2013, 

or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture of pesticides, biocides, or topical antiseptics in each of the following 

years: (Use either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of pesticides, 

biocides, and topical antiseptics manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture pesticides, biocides, or topical antiseptics in each of the following years: (Use either 

metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import pesticides, biocides, or topical antiseptics containing mercury or mercury

compounds in 2010, 2013, or 2016?
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported pesticides, biocides, or topical antiseptics per year(s): (Use either metric or U.S. customary 

units)

Agricultural applications 2010 2013 2016 

Interior/exterior paints 2010 2013 2016 

Other pesticides, biocides, and topical antiseptics 2010 2013 2016 

If “other,” then provide a general description of the pesticides, biocides, or topical antiseptics:

Did your company export pesticides, biocides, or topical antiseptics containing mercury or mercury

compounds in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported pesticides, biocides, or topical antiseptics per year(s): (Use either metric or U.S. customary 

units)

Agricultural applications 2010 2013 2016 

Interior/exterior paints 2010 2013 2016 

Other pesticides, biocides, and topical antiseptics 2010 2013 2016 

If “other,” then provide a general description of the pesticides, biocides, or topical antiseptics:

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 9: Pumps

Did your company manufacture pumps that contain mercury or mercury compounds in 2010, 2013, or 

2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

pumps per year(s): (Use either metric or U.S. customary units)

Pumps 2010 2013 2016 

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of pumps manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture pumps in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of pumps

manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture of pumps in each of the following years: (Use either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import pumps containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported pumps per year(s): (Use either metric or U.S. customary units)
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Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Pumps 2010 2013 2016 

Did your company export pumps containing mercury or mercury compounds in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported pumps per year(s): (Use either metric or U.S. customary units)

Pumps 2010 2013 2016 

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 10: Measuring Instruments

Did your company manufacture measuring instruments that contain mercury or mercury compounds in 

2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

measuring instruments per year(s): (Use either metric or U.S. customary units)

Barometer 2010 2013 2016 

Fever thermometer 2010 2013 2016 

Flow meter 2010 2013 2016 

Hydrometer 2010 2013 2016 

Hygrometer/psychrometer 2010 2013 2016 

Manometer 2010 2013 2016 

Non-fever thermometer 2010 2013 2016 

Pyrometer 2010 2013 2016 

Sphygmomanometer 2010 2013 2016 

Other measuring instruments 2010 2013 2016 

If “other,” then provide a general description of the measuring instruments:

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of measuring instruments manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture measuring instruments in each of the following years: (Use either metric 

or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of measuring 

instruments manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture of measuring instruments in each of the following years: (Use either metric or U.S. 

customary units)
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

2010 __________

2013 __________

2016 __________

Did your company import measuring instruments containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported measuring instruments per year(s): (Use either metric or U.S. customary units)

Barometer 2010 2013 2016 

Fever thermometer 2010 2013 2016 

Flow meter 2010 2013 2016 

Hydrometer 2010 2013 2016 

Hygrometer/psychrometer 2010 2013 2016 

Manometer 2010 2013 2016 

Non-fever thermometer 2010 2013 2016 

Pyrometer 2010 2013 2016 

Sphygmomanometer 2010 2013 2016 

Other measuring instruments 2010 2013 2016 

If “other,” then provide a general description of the measuring instruments:

Did your company export measuring instruments containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported measuring instruments per year(s): (Use either metric or U.S. customary units)

Barometer 2010 2013 2016 

Fever thermometer 2010 2013 2016 

Flow meter 2010 2013 2016 

Hydrometer 2010 2013 2016 

Hygrometer/psychrometer 2010 2013 2016 

Manometer 2010 2013 2016 

Non-fever thermometer 2010 2013 2016 

Pyrometer 2010 2013 2016 

Sphygmomanometer 2010 2013 2016 

Other measuring instruments 2010 2013 2016 
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

If “other,” then provide a general description of the measuring instruments:

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 11: Switches, Relays, Sensors, Valves

Did your company manufacture switches, relays, sensors, or valves that contain mercury or mercury

compounds in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

switches, relays, sensors, or valves per year(s): (Use either metric or U.S. customary units)

Tilt switch 2010 2013 2016 

Vibration switch 2010 2013 2016 

Float switch 2010 2013 2016 

Pressure switch 2010 2013 2016 

Temperature switch 2010 2013 2016 

Displacement relay 2010 2013 2016 

Wetted reed relay 2010 2013 2016 

Contact relay 2010 2013 2016 

Flame sensor 2010 2013 2016 

Thermostat 2010 2013 2016 

Other switches, relays, sensors, valves 2010 2013 2016 

If “other,” then provide a general description of the switches, relays, sensors, or valves:

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of switches, relays, sensors, or valves manufactured by your company in 2010, 2013, or 

2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture switches, relays, sensors, or valves in each of the following years: (Use 

either metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of switches, 

relays, sensors, or valves manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture of switches, relays, sensors, or valves in each of the following years: (Use either metric 

or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import switches, relays, sensors, or valves containing mercury or mercury

compounds in 2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

imported switches, relays, sensors, or valves per year(s): (Use either metric or U.S. customary units)

Tilt switch 2010 2013 2016 

Vibration switch 2010 2013 2016 

Float switch 2010 2013 2016 

Pressure switch 2010 2013 2016 

Temperature switch 2010 2013 2016 

Displacement relay 2010 2013 2016 

Wetted reed relay 2010 2013 2016 

Contact relay 2010 2013 2016 

Flame sensor 2010 2013 2016 

Thermostat 2010 2013 2016 

Other switches, relays, sensors, valves 2010 2013 2016 

If “other,” then provide a general description of the switches, relays, sensors, or valves:

Did your company export switches, relays, sensors, or valves containing mercury or mercury

compounds in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide the total amount of mercury or mercury compounds in each of the following types of 

exported switches, relays, sensors, or valves per year(s): (Use either metric or U.S. customary units)

Tilt switch 2010 2013 2016 

Vibration switch 2010 2013 2016 

Float switch 2010 2013 2016 

Pressure switch 2010 2013 2016 

Temperature switch 2010 2013 2016 

Displacement relay 2010 2013 2016 
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Wetted reed relay 2010 2013 2016 

Contact relay 2010 2013 2016 

Flame sensor 2010 2013 2016 

Thermostat 2010 2013 2016 

Other switches, relays, sensors, valves 2010 2013 2016 

If “other,” then provide a general description of the switches, relays, sensors, or valves:

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S) 

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 12: Miscellaneous Mercury-Added Products

Did your company manufacture mercury-added products not otherwise described in the categories 

described in the table in Section 2 that contain mercury or mercury compounds in 2010, 2013, or 

2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of mercury-added products manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture mercury-added products in each of the following years: (Use either metric 

or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of mercuryadded products manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture mercury-added products in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________

2013 __________

2016 __________
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Did your company import mercury-added products containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Did your company export mercury-added products containing mercury or mercury compounds in 2010, 

2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Additional comments: 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Section 13: Products Derived from the Use of Mercury or Mercury Compounds in a 

Manufacturing Process

Did your company manufacture mercury-added products derived from the use of mercury or mercury

compounds in a manufacturing process including, but not limited to acetaldehyde production in which 

mercury or mercury compounds are used as a catalyst; vinyl chloride monomer production; sodium or 

potassium methylate or ethylate; or production of polyurethane using mercury containing-catalysts in 

2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Did your company purchase in the United States mercury or mercury compounds to be used in the 

production of mercury-added products derived from the use of mercury or mercury compounds in a 

manufacturing process manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (3) of this section.

Yes

If yes, then provide the total amount of domestically purchased mercury or mercury compounds used by

your company to manufacture such mercury-added products in each of the following years: (Use either 

metric or U.S. customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury or mercury compounds to be used in the production of mercuryadded products derived from the use of mercury or mercury compounds in a manufacturing process 

manufactured by your company in 2010, 2013, or 2016?

No; please proceed to question (4) of this section.

Yes
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

If yes, then provide the total amount of imported mercury or mercury compounds used by your company

to manufacture such mercury-added products in each of the following years: (Use either metric or U.S. 

customary units)

2010 __________

2013 __________

2016 __________

Did your company import mercury-added products derived from the use of mercury or mercury

compounds in a manufacturing process in 2010, 2013, or 2016?

No; please proceed to question (5) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Did your company export mercury-added products derived from the use of mercury or mercury

compounds in a manufacturing process in 2010, 2013, or 2016?

No; please proceed to question (6) of this section.

Yes

If yes, then provide a general description of the product and the total amount of mercury or mercury 

compounds used per year(s): (Use either metric or U.S. customary units)

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

2010 2013 2016 

Additional comments: 

___________________________________________________________________________
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

___________________________________________________________________________

___________________________________________________________________________

IF THERE ARE NO ADDITIONAL COMMENTS, THEN PLEASE PROCEED TO ANY ADDITIONAL

CATEGORIES YOU CHECKED IN THE TABLE IN SECTION 2.

IF YOUR COMPANY DID NOT MANUFACTURE, IMPORT, OR EXPORT ANY ADDITIONAL PRODUCT(S)

CONTAINING MERCURY OR MERCURY COMPOUNDS OR USE MERCURY OR MERCURY COMPOUNDS 

IN A MANUFACTURING PROCESS(ES), THEN DO NOT COMPLETE ANY ADDITIONAL SECTIONS OF THIS 

QUESTIONNAIRE.
INTERNAL, DELIBERATIVE – USG USE ONLY

Questionnaire

Collection of Information on Use of Mercury and Mercury Compounds in Products and Processes

OMB Control No. 2070-NEW

Paperwork Reduction Act Notice: The annual public burden for this collection of information is 

estimated to be 2,566 hours. Send comments regarding the burden estimate or any other aspect of the 

collection of information, including suggestions for reducing the burden to: Director, Collection 

Strategies Division, Office of Environmental Information (OEI), U.S. Environmental Protection Agency

(Mail Code 2822), 1200 Pennsylvania Avenue, N.W., Washington, D.C. 20460. Include OMB number 

2070-NEW in any correspondence. Do not send the completed form or requested form or requested 

information to this address. The actual information or form should be submitted in accordance with the 

accompanying instructions, or as specified in the corresponding regulations.