List of Instruments for Phase 1 and 2, NCS Vanguard (Pilot) Study

OMB #: 0925-0593

Expiration Date: 7/31/2013

Phase II

List of Instruments for NCS Vanguard (Pilot) Study - Phase 1 and 2
Activity	Type of Respondent	Instruments
Screening Activities
Address Lookup Tool (PB)	Age-Eligible Women	Address Lookup Tool (ALT) User's Guide
Pregnancy Screener (PB, EH, TT-HI)	Age-Eligible Women	Pregnancy Screener (PB) Pregnancy Screener (EH) Pregnancy Screener (TT-LI, TT-HI)
Healthcare Provider Questionnaire (PB)	Healthcare Providers	Healthcare Provider Questionnaire
Household Enumeration Instrument (EH)	HH Reporters	Household Enumeration Instrument
Low-intensity Invitation to High-intensity Script (TT-HI)	Age-Eligible Women	Low-Intensity Invitation to High-Intensity Script
Pregnancy Screener (TT-LI, TT-HI)	Age-Eligible Women	Pregnancy Screener (TT-LI, TT-HI)
Low-Intensity Consent Script (TT-LI)	Age-Eligible Women	Low-Intensity Consent Script
Preconception Activities
Non-pregnant Women's Informed Consent (PB, EH, TT-HI)	Age-Eligible Women	Non-pregnant Women's Informed Consent
Pre-Pregnancy Interview (PB, EH, TT-HI)	Age-Eligible Women	Pre-Pregnancy Interview Pre-Pregnancy SAQ
Biological and Environmental Sample Collection - Preconception (PB, EH, TT-HI)	Age-Eligible Women	Biospecimens Urine Instrument Biospecimens Blood Instrument Note to File - Biological and Environmental Sample Collection
Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI)	Age-Eligible Women	Pregnancy Probability Group Follow Up - CATI Instrument Pregnancy Probability Group Follow Up - SAQ
Low-intensity Questionnaire (Non-Pregnant) (TT-LI)	Age-Eligible Women	Low-Intensity Questionnaire (Non- & Pregnant)
Validation Script (PB, EH, TT-HI, TT-LI)	Age-Eligible Women	Interviewer Validation
Pregnancy Activities
Pregnant Women's Informed Consent Form (PB, EH, TT-HI)	Pregnant Women	Pregnant Women's Informed Consent Form
Low-intensity Questionnaire (Found Pregnant) (TT-LI)	Pregnant Women	Low-Intensity Questionnaire (Non- & Pregnant)
Pregnancy Visit 1 Interview (PB, EH, TT-HI)	Pregnant Women	Pregnancy Visit 1 Interview Pregnancy Visit 1 SAQ
Biological and Environmental Sample Collection - Pregnancy (PB, EH, TT-HI)	Pregnant Women	Biospecimens Urine Instrument Biospecimens Blood Instrument Note to File - Biological and Environmental Sample Collection
Pregnancy Visit 2 Interview (PB, EH, TT-HI)	Pregnant Women	Pregnancy Visit 2 Interview Pregnancy Visit 2 SAQ
Activity	Type of Respondent	Instruments
Pregnancy Activities (Cont.)
Pregnancy Health Care Log (PB, EH, TT-HI)	Pregnant Women	Pregnancy Health Care Log
Father Informed Consent Form (PB, EH, TT-HI)	Alternate Caregiver	Informed Consent Form - Fathers
Father Interview (PB, EH, TT-HI)	Alternate Caregiver	Father Interview
Birth-Related Activities
Birth Visit Interview (PB, EH, TT-HI)	Mother/Baby	Birth Visit Interview Note to File - Birth Visit - Umbilical Cord Collection
Low-intensity Questionnaire (Birth-focus) (TT-LI)	Mother/Baby	Low-Intensity Birth Visit Interview
Postnatal Activities
Infant Feeding Log (PB, EH, TT-HI)	Mother/Baby	Infant and Child Health Care Log
Low-intensity Questionnaire (Child-focus) (TT-LI)	Mother/Baby	Low-Intensity Questionnaire (Non- & Pregnant)
3-Month Phone Call (PB, EH, TT-HI)	Mother/Baby	3-Month Mother Phone Interview
6-Month Visit Interview (PB, EH, TT-HI)	Mother/Baby	6-Month Mother Interview6-Month Infant Feeding SAQ
9-Month Phone Call (PB, EH, TT-HI)	Mother/Baby	9-Month Mother Phone Interview
12-Month Visit Interview (PB, EH, TT-HI)	Mother/Baby	12-Month Mother Interview 12-Month SAQ
18-Month Maternal Phone Call (PB, EH, TT-HI)	Mother/Baby	18-Month Mother Interview 18-Month SAQ (placeholder for copyrighted material -- Ages and Stages III Questionnaire) (Placeholder for copyrighted material)
24-Month Maternal Phone Call (PB, EH, TT-HI)	Mother/Baby	24-Month Mother Interview 24-Month SAQ (placeholder for copyrighted material -- Ages and Stages III Questionnaire) (Placeholder for copyrighted material)
Formative Research
Formative - Developmental	Other	Note to file - Formative Research

The following documents will be placed under the "Files" tab in ICRAS.

Files

Refusal of Biological/Environmental Samples

Urine Collection Instructions

Pre-Visit Instructions for Blood and Urine Collection

Pre-Visit Instructions for Fasting Blood, Urine, and Vacuum Collection

Pre-Visit Instructions for Non Fasting Venous Blood, Adult Urine, and Vacuum Collection

Pre-Visit Instructions for Blood and Urine Collection

Vacuum Bag Participant Instructions

Tap Water Collections (TWF)

Tap Water Collections (TWQ)

Pre-Pregnancy Visit Information Sheet

Pregnancy Visit 1 Visit Information Sheet

Pregnancy Visit 2 Visit Information Sheet

Father Visit Information Sheet

Low-Intensity Data Collection Participant Information Sheet

Birth Visit Information Sheet (with samples)

Birth Visit Information Sheet (without samples)

6-Month Visit Information Sheet

12-Month Visit Information Sheet

Supporting Statement A

Supporting Statement B

Itemized Burden Estimate

List of Instruments for Phase 1 and 2, NCS Vanguard (Pilot) Study