OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Questionaire Packets

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

Documents and Forms
Document Name
Document Type
Other-HIPAA Release Forms
Other-Autoimmune Disease Survey
Other-Carey Temperament Scales
Other-Child Behavior Checklist
Other-Survey of Gastrointestinal Fun
Other-Maternal Medical History
Other-Paternal Medical History
Other-Paternal Occupational Question
Other-Child's Sleep Habits Questionn
Other-Social Responsiveness Scale (A
Other-Social Responsiveness Scale (C
Other-3 Day Diet Diary
Other-7 Day Stool Diary
Other-Self Administered Consent
Other-Self Administered Consent
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Questionaire Packets
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Public Health Monitoring

09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

3,456 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 44,928 0 44,928 0 0 0
Annual IC Time Burden (Hours) 12,384 0 12,384 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.