NIH Toolbox for Assessment of Neurological and Behavioral Function (NIA)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 40 Initial Child/Proxy Questionaire	Form and Instruction	New	Available
Form 59 Education Proxy Report for Children	Form and Instruction	New	Available
Form 54 Socio-demographic form	Form and Instruction	New	Available
Form 53 School Performance and Activities	Form and Instruction	New	Available
Form 51 Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue	Form and Instruction	New	Available
Form 48 Pediatric Perceived Cognitive Proxy	Form and Instruction	New	Available
Form 44 Health Care Access and Utilization	Form and Instruction	New	Available
Form 43 Cognition Information Form	Form and Instruction	New	Available
Form 27 Handedness Assessment	Form and Instruction	New	Available
Form 42 Additional Audition Olfaction Taste	Form and Instruction	New	Available
Form 41 Additional Somatosensation Questions	Form and Instruction	New	Available
Form 32 Supplemental Emotional Health Questionaire	Form and Instruction	New	Available
Form 31 Emotional Health Questionaire	Form and Instruction	New	Available
Form 9 Pain Assessment Ages 8-12	Form and Instruction	New	Available
Form 8 Pain Assessment Ages 8-12	Form and Instruction	New	Available
Form 7 Pain Assessment Ages 3-7	Form and Instruction	New	Available
Form 9 Pain Assessment Ages 13-17	Form and Instruction	New	Available
Form 8 Pain Assessment Ages 8-12	Form and Instruction	New	Available
Form 7 Pain Assessment Ages 3-7	Form and Instruction	New	Available
Form 5 Odor Identification	Form and Instruction	New	Available
Form 55 Text Anxiety Scale	Form and Instruction	New	Available
Form 57 EtOH (Alcohol) Questionaire	Form and Instruction	New	Available
Form 52 PROMIS 29 Participant	Form and Instruction	New	Available
Form 51 Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue	Form and Instruction	New	Available
Form 50 Pediatric PROMIS Physical Function Mobility	Form and Instruction	New	Available
Form 49 Pediatric PROMIS Physical Function Upper Extremity	Form and Instruction	New	Available
Form 47 Pediatric Perceived Cognitive Child	Form and Instruction	New	Available
Form 42 Additional Audition Olfaction Taste	Form and Instruction	New	Available
Form 41 Additional Somatosensation Questions	Form and Instruction	New	Available
Form 40 Initial Child/Proxy Questionaire	Form and Instruction	New	Available
Form 38 Balance Accelerometer Measure	Form and Instruction	New	Available
Form 37 Strength Knee Extension	Form and Instruction	New	Available
Form 36 Grip Strength Dynamometry	Form and Instruction	New	Available
Form 35 Locomotion 4-meter Walk Test	Form and Instruction	New	Available
Form 34 Endurance 2-Minute Walk Test	Form and Instruction	New	Available
Form 33 Dexterity 9-hole Pegboard	Form and Instruction	New	Available
Form 32 Supplemental Emotional Health Questionaire	Form and Instruction	New	Available
Form 31 Emotional Health Questionaire	Form and Instruction	New	Available
Form 29 Word Accentuation (Spanish only)	Form and Instruction	New	Available
Form 28 Vocabulary Comprehension	Form and Instruction	New	Available
Form 27 Handedness Assessment	Form and Instruction	New	Available
Form 26 Reading Recognition	Form and Instruction	New	Available
Form 24 Pattern Comparison	Form and Instruction	New	Available
Form 23 Oral Symbol Digit Modalities	Form and Instruction	New	Available
Form 22 List Sorting	Form and Instruction	New	Available
Form 20 Imitation Based Assessment of Memory	Form and Instruction	New	Available
Form 19 Bateria III Picture Vocabulary (Spanish only)	Form and Instruction	New	Available
Form 18 Dimensional Card Change Sort	Form and Instruction	New	Available
Form 17 Tactile Discrimination Test	Form and Instruction	New	Available
Form 15 Brief Kinesthesia Test	Form and Instruction	New	Available
Form 14 Vision Health Related QOL Survey	Form and Instruction	New	Available
Form 13 Dynamic Visual Acuity (DVA)	Form and Instruction	New	Available
Form 12 Toolbox Taste Test	Form and Instruction	New	Available
Form 11 Sucrose Preference Test	Form and Instruction	New	Available
Form 4 Ordor Identification	Form and Instruction	New	Available
Form 3 Words in Noise	Form and Instruction	New	Available
Form 6 University of Penn Smell Identification	Form and Instruction	New	Available
Form 1 Automated Audiometry from the NIH Toolbox (AANT)	Form and Instruction	New	Available
Form 56 Falls Efficscy Scale-International	Form and Instruction	New	Available
Form 55 Text Anxiety Scale	Form and Instruction	New	Available
Form 59 Education Proxy Report for Children	Form and Instruction	New	Available
Form 58 Education Adult Self-Report	Form and Instruction	New	Available
Form 57 EtOH (Alcohol) Questionaire	Form and Instruction	New	Available
Form 52 PROMIS 29 Participant	Form and Instruction	New	Available
Form 46 Applied Cognition Adult	Form and Instruction	New	Available
Form 45 Instrumental Activities of Daily Living	Form and Instruction	New	Available
Form 44 Health Care Access and Utilization	Form and Instruction	New	Available
Form 43 Cognition Information Form	Form and Instruction	New	Available
Form 42 Additional Audition Olfaction Taste	Form and Instruction	New	Repair queued
Form 41 Additional Somatosensation Questions	Form and Instruction	New	Available
Form 39 Initial Adult Questionaire	Form and Instruction	New	Available
Form 38 Balance Accelerometer Measure	Form and Instruction	New	Available
Form 37 Strength Knee Extension	Form and Instruction	New	Available
Form 36 Grip Strength Dynamometry	Form and Instruction	New	Available
Form 35 Locomotion 4-meter Walk Test	Form and Instruction	New	Available
Form 34 Endurance 2-Minute Walk Test	Form and Instruction	New	Available
Form 33 Dexterity 9-hole Pegboard	Form and Instruction	New	Available
Form 32 Supplemental Emotional Health Questionaire	Form and Instruction	New	Available
Form 31 Emotional Health Questionaire	Form and Instruction	New	Available
Form 29 Word Accentuation (Spanish only)	Form and Instruction	New	Available
Form 28 Vocabulary Comprehension	Form and Instruction	New	Available
Form 27 Handedness Assessment	Form and Instruction	New	Available
Form 26 Reading Recognition	Form and Instruction	New	Available
Form 24 Pattern Comparison	Form and Instruction	New	Available
Form 23 Oral Symbol Digit Modalities	Form and Instruction	New	Available
Form 22 List Sorting	Form and Instruction	New	Available
Form 20 Imitation Based Assessment of Memory	Form and Instruction	New	Available
Form 19 Bateria III Picture Vocabulary (Spanish only)	Form and Instruction	New	Available
Form 18 Dimensional Card Change Sort	Form and Instruction	New	Available
Form 17 Tactile Discrimination Test	Form and Instruction	New	Available
Form 15 Brief Kinesthesia Test	Form and Instruction	New	Available
Form 14 Vision Health Related QOL Survey	Form and Instruction	New	Available
Form 13 Dynamic Visual Acuity (DVA)	Form and Instruction	New	Available
Form 12 Toolbox Taste Test	Form and Instruction	New	Available
Form 11 Sucrose Preference Test	Form and Instruction	New	Available
Form 10 PA Ages 18-85	Form and Instruction	New	Available
Form 4 Ordor Identification	Form and Instruction	New	Available
Form 3 Words in Noise	Form and Instruction	New	Available
Form 6 University of Penn Smell Identification	Form and Instruction	New	Available
Form 1 Automated Audiometry from the NIH Toolbox (AANT)	Form and Instruction	New	Repair queued
Form 2 Hearing Handicap Inventory (HHI)	Form and Instruction	New	Available
Attach 63 Consent Documents 7.24.2011.pdf	Supplementary Document	Uploaded 2011-07-25	Available
Attach 62 - NU IRB Approval Letter 7.24.2011.pdf	Supplementary Document	Uploaded 2011-07-25	Available
Attach 61 Certificate of Confidentiality 7.24.2011.pdf	Supplementary Document	Uploaded 2011-07-25	Available
Attach 60 Recruitment instructions scripts and letters 7.24.2011.pdf	Supplementary Document	Uploaded 2011-07-25	Available
Supporting_Statement_B1_7-24-2011.docx	Supporting Statement B	Uploaded 2011-07-25	Available
Attach 65 NIH Privacy Review Act Memo cover.docx	Supplementary Document	Uploaded 2011-05-27	Available
Attach 64 Team Member Contact List.pdf	Supplementary Document	Uploaded 2011-05-25	Available
Supporting_Statement_A2_comments 7-24-2011.docx	Supporting Statement A	Uploaded 2011-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Initial Child/Proxy Questionaire
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Education Proxy Report for Children
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Socio-demographic form
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	School Performance and Activities
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Pediatric Perceived Cognitive Proxy
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Health Care Access and Utilization
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Cognition Information Form
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Handedness Assessment
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Additional Audition Olfaction Taste
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Additional Somatosensation Questions
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Supplemental Emotional Health Questionaire
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Emotional Health Questionaire
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 8-12
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 8-12
197920	Parent Proxies (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 3-7
197920	Parent Proxies (baseline only + retest)	Instruction	New
197919	Children (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 13-17
197919	Children (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 8-12
197919	Children (baseline only + retest)	Form and Instruction	New	Pain Assessment Ages 3-7
197919	Children (baseline only + retest)	Form and Instruction	New	Odor Identification
197919	Children (baseline only + retest)	Form and Instruction	New	Text Anxiety Scale
197919	Children (baseline only + retest)	Form and Instruction	New	EtOH (Alcohol) Questionaire
197919	Children (baseline only + retest)	Form and Instruction	New	PROMIS 29 Participant
197919	Children (baseline only + retest)	Form and Instruction	New	Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue
197919	Children (baseline only + retest)	Form and Instruction	New	Pediatric PROMIS Physical Function Mobility
197919	Children (baseline only + retest)	Form and Instruction	New	Pediatric PROMIS Physical Function Upper Extremity
197919	Children (baseline only + retest)	Form and Instruction	New	Pediatric Perceived Cognitive Child
197919	Children (baseline only + retest)	Form and Instruction	New	Additional Audition Olfaction Taste
197919	Children (baseline only + retest)	Form and Instruction	New	Additional Somatosensation Questions
197919	Children (baseline only + retest)	Form and Instruction	New	Initial Child/Proxy Questionaire
197919	Children (baseline only + retest)	Form and Instruction	New	Balance Accelerometer Measure
197919	Children (baseline only + retest)	Form and Instruction	New	Strength Knee Extension
197919	Children (baseline only + retest)	Form and Instruction	New	Grip Strength Dynamometry
197919	Children (baseline only + retest)	Form and Instruction	New	Locomotion 4-meter Walk Test
197919	Children (baseline only + retest)	Form and Instruction	New	Endurance 2-Minute Walk Test
197919	Children (baseline only + retest)	Form and Instruction	New	Dexterity 9-hole Pegboard
197919	Children (baseline only + retest)	Form and Instruction	New	Supplemental Emotional Health Questionaire
197919	Children (baseline only + retest)	Form and Instruction	New	Emotional Health Questionaire
197919	Children (baseline only + retest)	Instruction	New
197919	Children (baseline only + retest)	Form and Instruction	New	Word Accentuation (Spanish only)
197919	Children (baseline only + retest)	Form and Instruction	New	Vocabulary Comprehension
197919	Children (baseline only + retest)	Form and Instruction	New	Handedness Assessment
197919	Children (baseline only + retest)	Form and Instruction	New	Reading Recognition
197919	Children (baseline only + retest)	Form and Instruction	New	Pattern Comparison
197919	Children (baseline only + retest)	Form and Instruction	New	Oral Symbol Digit Modalities
197919	Children (baseline only + retest)	Form and Instruction	New	List Sorting
197919	Children (baseline only + retest)	Form and Instruction	New	Imitation Based Assessment of Memory
197919	Children (baseline only + retest)	Form and Instruction	New	Bateria III Picture Vocabulary (Spanish only)
197919	Children (baseline only + retest)	Form and Instruction	New	Dimensional Card Change Sort
197919	Children (baseline only + retest)	Form and Instruction	New	Tactile Discrimination Test
197919	Children (baseline only + retest)	Form and Instruction	New	Brief Kinesthesia Test
197919	Children (baseline only + retest)	Form and Instruction	New	Vision Health Related QOL Survey
197919	Children (baseline only + retest)	Form and Instruction	New	Dynamic Visual Acuity (DVA)
197919	Children (baseline only + retest)	Form and Instruction	New	Toolbox Taste Test
197919	Children (baseline only + retest)	Form and Instruction	New	Sucrose Preference Test
197919	Children (baseline only + retest)	Form and Instruction	New	Ordor Identification
197919	Children (baseline only + retest)	Form and Instruction	New	Words in Noise
197919	Children (baseline only + retest)	Form and Instruction	New	University of Penn Smell Identification
197919	Children (baseline only + retest)	Form and Instruction	New	Automated Audiometry from the NIH Toolbox (AANT)
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Falls Efficscy Scale-International
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Text Anxiety Scale
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Education Proxy Report for Children
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Education Adult Self-Report
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	EtOH (Alcohol) Questionaire
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	PROMIS 29 Participant
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Applied Cognition Adult
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Instrumental Activities of Daily Living
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Health Care Access and Utilization
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Cognition Information Form
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Additional Audition Olfaction Taste
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Additional Somatosensation Questions
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Initial Adult Questionaire
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Balance Accelerometer Measure
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Strength Knee Extension
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Grip Strength Dynamometry
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Locomotion 4-meter Walk Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Endurance 2-Minute Walk Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Dexterity 9-hole Pegboard
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Supplemental Emotional Health Questionaire
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Emotional Health Questionaire
197918	Adult Study Participants (baseline only + 1 retest)	Instruction	New
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Word Accentuation (Spanish only)
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Vocabulary Comprehension
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Handedness Assessment
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Reading Recognition
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Pattern Comparison
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Oral Symbol Digit Modalities
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	List Sorting
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Imitation Based Assessment of Memory
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Bateria III Picture Vocabulary (Spanish only)
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Dimensional Card Change Sort
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Tactile Discrimination Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Brief Kinesthesia Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Vision Health Related QOL Survey
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Dynamic Visual Acuity (DVA)
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Toolbox Taste Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Sucrose Preference Test
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	PA Ages 18-85
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Ordor Identification
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Words in Noise
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	University of Penn Smell Identification
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Automated Audiometry from the NIH Toolbox (AANT)
197918	Adult Study Participants (baseline only + 1 retest)	Form and Instruction	New	Hearing Handicap Inventory (HHI)

ICR Details

OMB Control No: 0925-0638	ICR Reference No: 201105-0925-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: NIH Toolbox for Assessment of Neurological and Behavioral Function (NIA)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/25/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/31/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved
Responses	19,350	0	0
Time Burden (Hours)	37,800	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Although there are many studies that collect information on aspects of neurological function and behavioral health (e.g., cognition, sensation, motor functioning, emotion), there is little uniformity among the measures used to assess these constructs. When individual studies employ unique assessment batteries, comparisons between studies and combining data from multiple studies are quite challenging. Thus, investigators have expressed the need for brief, standard assessment tools to be used across diverse study designs and populations. For example, in 2005, a report (Hendrie et al., Alzheimer's & Dementia, vol. 2, 12-32, 2006) was submitted to the staff of the trans-NIH Cognitive and Emotional Health Project (CEHP) that suggested, among other ideas, the need for "standard questionnaires to measure cognitive and emotional health". In response to these issues, the National Institutes of Health (NIH) Toolbox initiative seeks to assemble brief, comprehensive assessment tools to measure cognitive, emotional, sensory and motor function that will be useful to clinicians and researchers in a variety of settings, with a particular emphasis on measuring outcomes in large longitudinal or epidemiologic studies and prevention or intervention trials across the lifespan. Such comprehensive measures are rarely included in studies of this type, due in part to the lack of brief, well-validated instruments.

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Authorizing Statute(s): US Code: 42 USC 410 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 1621	01/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 22107	04/20/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Adult Study Participants (baseline only + 1 retest)	24, 26, 27, 28, 29, 31, 32, 33, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 46, 52, 57, 58, 59, 55, 56, 34, 2, 1, 6, 3, 4, 10, 11, 15, 12, 13, 14, 17, 18, 19, 20, 22, 23	Hearing Handicap Inventory (HHI) ,   Automated Audiometry from the NIH Toolbox (AANT) ,   University of Penn Smell Identification ,   Words in Noise ,   Ordor Identification ,   PA Ages 18-85 ,   Sucrose Preference Test ,   Toolbox Taste Test ,   Dynamic Visual Acuity (DVA) ,   Vision Health Related QOL Survey ,   Brief Kinesthesia Test ,   Tactile Discrimination Test ,   Dimensional Card Change Sort ,   Bateria III Picture Vocabulary (Spanish only) ,   Imitation Based Assessment of Memory ,   List Sorting ,   Oral Symbol Digit Modalities ,   Pattern Comparison ,   Reading Recognition ,   Handedness Assessment ,   Vocabulary Comprehension ,   Word Accentuation (Spanish only) ,   Emotional Health Questionaire ,   Supplemental Emotional Health Questionaire ,   Dexterity 9-hole Pegboard ,   Endurance 2-Minute Walk Test ,   Locomotion 4-meter Walk Test ,   Grip Strength Dynamometry ,   Strength Knee Extension ,   Balance Accelerometer Measure ,   Initial Adult Questionaire ,   Additional Somatosensation Questions ,   Additional Audition Olfaction Taste ,   Cognition Information Form ,   Health Care Access and Utilization ,   Instrumental Activities of Daily Living ,   Applied Cognition Adult ,   PROMIS 29 Participant ,   EtOH (Alcohol) Questionaire ,   Education Adult Self-Report ,   Education Proxy Report for Children ,   Text Anxiety Scale ,   Falls Efficscy Scale-International
Children (baseline only + retest)	1, 6, 3, 4, 11, 12, 13, 14, 15, 17, 18, 19, 20, 22, 23, 24, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 47, 49, 50, 51, 52, 57, 55, 5, 7, 8, 9	Automated Audiometry from the NIH Toolbox (AANT) ,   University of Penn Smell Identification ,   Words in Noise ,   Ordor Identification ,   Sucrose Preference Test ,   Toolbox Taste Test ,   Dynamic Visual Acuity (DVA) ,   Vision Health Related QOL Survey ,   Brief Kinesthesia Test ,   Tactile Discrimination Test ,   Dimensional Card Change Sort ,   Bateria III Picture Vocabulary (Spanish only) ,   Imitation Based Assessment of Memory ,   List Sorting ,   Oral Symbol Digit Modalities ,   Pattern Comparison ,   Reading Recognition ,   Handedness Assessment ,   Vocabulary Comprehension ,   Word Accentuation (Spanish only) ,   Emotional Health Questionaire ,   Supplemental Emotional Health Questionaire ,   Dexterity 9-hole Pegboard ,   Endurance 2-Minute Walk Test ,   Locomotion 4-meter Walk Test ,   Grip Strength Dynamometry ,   Strength Knee Extension ,   Balance Accelerometer Measure ,   Initial Child/Proxy Questionaire ,   Additional Somatosensation Questions ,   Additional Audition Olfaction Taste ,   Pediatric Perceived Cognitive Child ,   Pediatric PROMIS Physical Function Upper Extremity ,   Pediatric PROMIS Physical Function Mobility ,   Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue ,   PROMIS 29 Participant ,   EtOH (Alcohol) Questionaire ,   Text Anxiety Scale ,   Odor Identification ,   Pain Assessment Ages 3-7 ,   Pain Assessment Ages 8-12 ,   Pain Assessment Ages 13-17
Parent Proxies (baseline only + retest)	7, 8, 9, 31, 32, 41, 42, 27, 43, 44, 48, 51, 53, 54, 59, 40	Pain Assessment Ages 3-7 ,   Pain Assessment Ages 8-12 ,   Pain Assessment Ages 8-12 ,   Emotional Health Questionaire ,   Supplemental Emotional Health Questionaire ,   Additional Somatosensation Questions ,   Additional Audition Olfaction Taste ,   Handedness Assessment ,   Cognition Information Form ,   Health Care Access and Utilization ,   Pediatric Perceived Cognitive Proxy ,   Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue ,   School Performance and Activities ,   Socio-demographic form ,   Education Proxy Report for Children ,   Initial Child/Proxy Questionaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	19,350	0	0	19,350	0	0
Annual Time Burden (Hours)	37,800	0	0	37,800	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $5,062,318

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/31/2011

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