A.1.1.c Survey

Appendix A A.1.1.c–1

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Neighbor Information (Eligibility) Form

INTRODUCTION: Hello, I’m (NAME) and am working with (LOCAL STUDY CENTER) on a large study of children’s health for the National Institutes of Health (SHOW ID BADGE). The study is called the National Children’s Study. I have been trying to contact the people who live at (TARGET DU ADDRESS).

	Neighbor
Is there anyone living at (TARGET DU ADDRESS)?	YES 1 NO 2 (END) DK 7 (END) RF 8 (END)
Are there any women ages 18 to 49 living there?	YES 1 NO 2 DK 7 (END) RF 8 (END)
When is a good time to find someone at home? ENTER ALL THAT APPLY	Time: a.m. p.m. Days: Before noon: 12 noon -4 pm: 4 pm- 8pm:
In case my supervisor wants to check my work, I would like to have your name, address, and phone number.	Name: Address: Phone:

END: Thank you for your time.

Comments: _________________________________________________________________

___________________________________________________________________________

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.