Information Collection

Questionaire Packets

IC 178540 under ICR 200702-0920-001 · OMB 0920-0741.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0741 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix E.18 HIPAA release form.doc	Other-HIPAA Release Forms
Appendix E.9 Autoimmune Survey.doc	Other-Autoimmune Disease Survey
Appendix E.10 Carey Temperment Scales.pdf	Other-Carey Temperament Scales
Appendix E.11 CBCL.pdf	Other-Child Behavior Checklist
Appendix E.12 GI questionnaire.doc	Other-Survey of Gastrointestinal Fun
Appendix E.13 Maternal MedHX 6-4-2007 .doc	Other-Maternal Medical History
Appendix E.14 Paternal MedHX 6-4-2007 .doc	Other-Paternal Medical History
Appendix E.15 PatOccup Hx.doc	Other-Paternal Occupational Question
Appendix E.16 Child Sleep Habits Q.pdf	Other-Child's Sleep Habits Questionn
Appendix E.17 SRS-adult version.pdf	Other-Social Responsiveness Scale (A
Appendix E.17 SRS-child version.doc	Other-Social Responsiveness Scale (C
Appendix H.1 3 Day Diet Diary.doc	Other-3 Day Diet Diary
Appendix H.2 7 Day Stool Diary.doc	Other-7 Day Stool Diary
Appendix E 3 Informed Consent Case 2007 06.doc	Other-Self Administered Consent
Appendix E.3 Informed Consent NIC&Sub6-4-2007.doc	Other-Self Administered Consent
Appendix E.1 Enrollment Packet Cover letters 6-4-07.doc Cover Letter	IC Document
Appendix E.2 Cover Sheet Yellow Folder Instructions.doc Cover Sheet	IC Document
Appendix E.4 Clinic Visit Prep Guide 6-4-2007 .doc Clinic Visit Prep Guide	IC Document
Appendix E.5 Caregiver Interview Prep Guide.doc Caregiver Interview Prep Guide	IC Document
Appendix E.6 Medical Glossary.doc Glossary Medical Terms	IC Document
Appendix E.8 Study Bill of Rights.doc Study Bill of Rights	IC Document
Appendix E.22 case cohort picture story.pdf Picture Story	IC Document
Appendix E.23 Questionnaire Checklist.doc Checklist of Questionnaire Packets	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Questionaire Packets

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Self Administered Consent	Appendix E 3 Informed Consent Case 2007 06.doc	Yes	Yes	Printable Only
Other-Self Administered Consent	Appendix E.3 Informed Consent NIC&Sub6-4-2007.doc	Yes	Yes	Printable Only
Other-Survey of Gastrointestinal Function	Appendix E.12 GI questionnaire.doc	Yes	Yes	Printable Only
Other-Maternal Medical History	Appendix E.13 Maternal MedHX 6-4-2007 .doc	Yes	Yes	Printable Only
Other-HIPAA Release Forms	Appendix E.18 HIPAA release form.doc	Yes	Yes	Printable Only
Other-Autoimmune Disease Survey	Appendix E.9 Autoimmune Survey.doc	Yes	Yes	Printable Only
Other-Carey Temperament Scales	Appendix E.10 Carey Temperment Scales.pdf	Yes	Yes	Printable Only
Other-Paternal Medical History	Appendix E.14 Paternal MedHX 6-4-2007 .doc	Yes	Yes	Printable Only
Other-Social Responsiveness Scale (Child)	Appendix E.17 SRS-child version.doc	Yes	Yes	Printable Only
Other-3 Day Diet Diary	Appendix H.1 3 Day Diet Diary.doc	Yes	Yes	Printable Only
Other-7 Day Stool Diary	Appendix H.2 7 Day Stool Diary.doc	Yes	Yes	Printable Only
Other-Paternal Occupational Questionnaire	Appendix E.15 PatOccup Hx.doc	Yes	Yes	Printable Only
Other-Child's Sleep Habits Questionnaire	Appendix E.16 Child Sleep Habits Q.pdf	Yes	Yes	Printable Only
Other-Social Responsiveness Scale (Adult)	Appendix E.17 SRS-adult version.pdf	Yes	Yes	Printable Only
Other-Child Behavior Checklist	Appendix E.11 CBCL.pdf	Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 3,456

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44,928	44,928
Annual IC Time Burden (Hours)	12,384	12,384
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	Appendix E.1 Enrollment Packet Cover letters 6-4-07.doc	06/05/2007
Cover Sheet	Appendix E.2 Cover Sheet Yellow Folder Instructions.doc	06/05/2007
Clinic Visit Prep Guide	Appendix E.4 Clinic Visit Prep Guide 6-4-2007 .doc	06/05/2007
Caregiver Interview Prep Guide	Appendix E.5 Caregiver Interview Prep Guide.doc	06/05/2007
Glossary Medical Terms	Appendix E.6 Medical Glossary.doc	06/05/2007
Study Bill of Rights	Appendix E.8 Study Bill of Rights.doc	06/05/2007
Picture Story	Appendix E.22 case cohort picture story.pdf	06/05/2007
Checklist of Questionnaire Packets	Appendix E.23 Questionnaire Checklist.doc	06/05/2007

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