1 Survey

Appendix A A.2.1.o–1

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Source: Visits: Within X Days of 6 Month Visit Mode: Self-administered (Mail-in) Estimated Time:		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

Baby (6-month-old)

3-Day Time and Place Diary

6 Month Visit

Instructions

1	This booklet contains instructions for the 6-Mo Baby 3-Day Time and Place Diary.
2	Fill out one Time and Place Diary [PUT LABEL HERE WITH DAYS THE RESPONDENT SHOULD FILL OUT THE DIARY – TWO WEEKDAYS AND ONE WEEKEND DAY] [EITHER TH, F, SA OR SU, M, TU]
3	Each Time and Place Diary asks about how and where your baby spent his/her time (we are most interested in WHERE your baby spent his/her time on each day).
4	In this diary, a day begins at 4:00 am in the early morning and ends at 3:59 am the following morning. For each hour of the day, write in generally what your baby was doing at that time.
5	The diary is designed for you to fill out based on your baby’s activities on the previous day. So, if you are to complete a diary for Sunday, then you should fill it out on Monday and if you are to complete a diary on Monday, you should fill it out on Tuesday, and so on. We would like you to complete the diary for 3 days, 1 weekend day, and 2 weekdays. The appropriate days are listed on the label above and on a label at the top of each day of the diary.
6	Use only a black ball-point pen (not red ink or felt tip) to mark the places where your baby spent his / her time. If your baby make a mistake, cross out the incorrect answer and draw a circle around the correct answer .

How to Complete Your Baby’s Diary

B eginning at 4:00 AM, think of everything your baby did for the next hour. Write in the activity number that corresponds to what your baby was doing for this hour. Check (_) a box for every place your baby was during that hour. Fill this out for 24 hours, ending at 3:59 AM (the next day). Fill out a diary for all of the days listed on page 1, or the cover sheet to this package.

Example 1: Let’s say from 4:00 AM to 5:59 AM, your baby was sleeping at home. Write the word “sleeping” under activities, and check the box for “Inside at home.”

For hours where your baby spent time multiple places, write generally what your baby did under “activities” and check a box for every place that your baby spent time during that hour.

Example 2: Let’s say your baby woke up at about 6:00 AM then you changed her diaper and dressed her for daycare, walked the dog outside with your baby in a stroller, and then you took your baby to daycare you would complete the diary as follows.

For hours where your baby was inside at daycare and did not leave, feel free to draw a line down for all of the hours your baby was at daycare. However, if you or someone else picked your baby up from daycare for an appointment, etc. please record that appropriately. Also, if you know that your baby’s care provider takes the child on a walk at 10:00, check the box for outside, at daycare.

Example 3: Let’s say from 8:00 AM to 11:59 AM, your baby was at daycare. Then at 11:59 AM, you picked up your baby for a doctor’s appointment.

Don’t worry too much if you have difficulty writing multiple activities in the “activities” column. This column is to help you remember what your baby did so you can check the box that corresponds to where he/she was.

It is okay to combine activities under one general title. For example, if your baby spent an hour at home in an exersaucer, or playing on an activity mat, you may write in “playing.”

Example 4: Let’s say that at 5:00 PM you picked your baby up at daycare, when you got home, your baby was playing in an exersaucer, then you fed and bathed your baby and put him/her to bed.

If you have any questions on how to fill out the diary, call 1-800-XXX-XXXX.

[ PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
Now fill in the diary below.

[ PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
Now fill in the diary below.

[ PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
N ow fill in the diary below.

Thank you very much for completing this time and place diary. Your answers are very important to the National Children’s Study.

Source: Visits: Within X Days of 12 Month, 24 Month Visit Mode: Self-administered (Mail-in) Estimated Time:		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

Child

3-Day Time and Place Diary

12/24 Month Visit

Instructions

1	This booklet contains instructions for the child 3-Day Time and Place Diary.
2	Fill out one Time and Place Diary [PUT LABEL HERE WITH DAYS THE RESPONDENT SHOULD FILL OUT THE DIARY – TWO WEEKDAYS AND ONE WEEKEND DAY] [EITHER TH, F, SA OR SU, M, TU]
3	Each Time and Place Diary asks about how and where your child spent his / her time (we are most interested in WHERE your child spent his/her time on each day).
4	In this diary, a day begins at 4:00 am in the early morning and ends at 3:59 am the following morning. For each hour of the day, write in generally what your child was doing at that time.
5	The diary is designed for you to fill out based on your child’s activities on the previous day. So, if you are to complete a diary for Sunday, then you should fill it out on Monday and if you are to complete a diary on Monday, you should fill it out on Tuesday, and so on. We would like you to complete the diary for 3 days, 1 weekend day, and 2 weekdays. The appropriate days are listed on the label above and on a label at the top of each day of the diary.
6	Use only a black ball-point pen (not red ink or felt tip) to mark the places where your child spent his / her time. If your child make a mistake, cross out the incorrect answer and draw a circle around the correct answer .

How to Complete Your Child’s Diary

B eginning at 4:00 AM, think of everything your child did for the next hour. Write-in the activity number that corresponds to what your child was doing for this hour. Check (_) a box for every place your child was during that hour. Fill this out for 24 hours, ending at 3:59 AM (the next day). Fill out a diary for all of the days listed on page 1, or the cover sheet to this package.

Example 1: Let’s say from 4:00 AM to 5:59 AM, your child was sleeping at home. Write the word “sleeping” under activities, and check the box for “Inside at home.”

For hours where your child spent time multiple places, write generally what your child did under “activities” and check a box for every place that your child spent time during that hour.

Example 2: Let’s say your child woke up at about 6:00 AM then you changed his/her diaper and dressed him/her for daycare, the two of you went outside for a walk, and then you took your child to daycare, you would complete the diary as follows.

For hours where your child was inside at daycare and did not leave, feel free to draw a line down for all of the hours your child was at daycare. However, if you or someone else picked your child up from daycare for an appointment, etc. please record that appropriately. Also, if you know that your child’s care provider takes the child on a walk at 10:00, check the box for outside, at daycare.

Example 3: Let’s say from 8:00 AM to 11:59 AM, your child was at daycare. Then at 11:59 AM, you picked up your child for a doctor’s appointment.

Don’t worry too much if you have difficulty writing multiple activities in the “activities” column. This column is to help you remember what your child did so you can check the box that corresponds to where he/she was.

It is okay to combine activities under one general title. For example, if your child spent an hour at home in an exersaucer, or playing on an activity mat, you may write in “playing.”

Example 4: Let’s say that at 5:00 PM you picked your child up at daycare, when you got home, your child was playing then you fed and bathed your child and put him/her to bed.

If you have any questions on how to fill out the diary, call 1-800-XXX-XXXX.

[PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
Now fill in the diary below.

[ PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
N ow fill in the diary below.

[ PUT LABEL HERE THAT LIST THE DAY [EITHER TH, F, SA OR SU, M, TU] AND THE DATE THE RESPONDENT SHOULD FILL OUT THE DIARY]
N ow fill in the diary below.

Thank you very much for completing this time and place diary. Your answers are very important to the National children’s Study.

Public reporting burden for this collection of information is estimated to average 15 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.