Information Collection

Children (baseline only + retest)

IC 197919 under ICR 201105-0925-006 · OMB 0925-0638.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 1
Children (baseline only + retest)
Form and Instruction
Attach 30 Instructions for Emotional Health Questionnaire.pdf Instruction
1 Automated Audiometry from the NIH Toolbox (AANT)
Attach 1 Automated Audiometry for the NIH Toolbox (AANT).pdf
Form and Instruction
6 University of Penn Smell Identification
Attach 6 University of Pennsylvania Smell Identification Test (UPSIT).pdf
Form and Instruction
3 Words in Noise
Attach 3 Words-In-Noise Test (WIN).pdf
Form and Instruction
4 Ordor Identification
Attach 4 Odor Identification Ages 10-85.pdf
Form and Instruction
11 Sucrose Preference Test
Attach 11 Sucrose Preference Test.pdf
Form and Instruction
12 Toolbox Taste Test
Attach 12 Toolbox Taste Test.pdf
Form and Instruction
13 Dynamic Visual Acuity (DVA)
Attach 13 Dynamic Visual Acuity (DVA).pdf
Form and Instruction
14 Vision Health Related QOL Survey
Attach 14 Vision Health-Related Quality of Life Survey.pdf
Form and Instruction
15 Brief Kinesthesia Test
Attach 15 Brief Kinesthesia Test.pdf
Form and Instruction
17 Tactile Discrimination Test
Attach 17 Tactile Discrimination Test.pdf
Form and Instruction
18 Dimensional Card Change Sort
Attach 18 Dimensional Change Card Sort.pdf
Form and Instruction
19 Bateria III Picture Vocabulary (Spanish only)
Attach 19 Bateria III Picture Vocabulary.pdf
Form and Instruction
20 Imitation Based Assessment of Memory
Attach 20 Flanker.pdf
Form and Instruction
22 List Sorting
Attach 22 List Sorting.pdf
Form and Instruction
23 Oral Symbol Digit Modalities
Attach 23 Oral Symbol Digit Modalities Test.pdf
Form and Instruction
24 Pattern Comparison
Attach 24 Pattern Comparison.pdf
Form and Instruction
26 Reading Recognition
Attach 26 Reading Recognition.pdf
Form and Instruction
27 Handedness Assessment
Attach 27 Determining Handedness.pdf
Form and Instruction
28 Vocabulary Comprehension
Attach 28 Vocabulary Comprehension.pdf
Form and Instruction
29 Word Accentuation (Spanish only)
Attach 29 Spanish Word Accentuation Test.pdf
Form and Instruction
31 Emotional Health Questionaire
Attach 31 Emotional Health Questionnaires for Toolbox.xlsx
Form and Instruction
32 Supplemental Emotional Health Questionaire
Attach 32 Supplemental Emotional Health Questionnaires.xls
Form and Instruction
33 Dexterity 9-hole Pegboard
Attach 33 9 Hole Pegboard.pdf
Form and Instruction
34 Endurance 2-Minute Walk Test
Attach 34 Endurance 2 Minute Walk Test (2MWT).pdf
Form and Instruction
35 Locomotion 4-meter Walk Test
Attach 35 Locomotion 4 Meter Walk Test.pdf
Form and Instruction
36 Grip Strength Dynamometry
Attach 36 Grip Strength Dynamometry.pdf
Form and Instruction
37 Strength Knee Extension
Attach 37 Strength Knee Extension.pdf
Form and Instruction
38 Balance Accelerometer Measure
Attach 38 Balance Accelerometer Measure (BAM).pdf
Form and Instruction
40 Initial Child/Proxy Questionaire
Attach 40 Initial Questionnaire-Proxy and Child.pdf
Form and Instruction
41 Additional Somatosensation Questions
Attach 41 Additional Somatosensation Questions.pdf
Form and Instruction
42 Additional Audition Olfaction Taste
Attach 42 Additional Audition Olfaction Taste Questions.pdf
Form and Instruction
47 Pediatric Perceived Cognitive Child
Attach 47 Pediatric Perceived Cognitive Function (PCF) - Child.pdf
Form and Instruction
49 Pediatric PROMIS Physical Function Upper Extremity
Attach 49 PROMIS Pediatric Physical Function Upper Extremity.pdf
Form and Instruction
50 Pediatric PROMIS Physical Function Mobility
Attach 50 PROMIS Pediatric Physical Function Mobility.pdf
Form and Instruction
51 Pediatric Funtional Assessment of Chronic Illness Therap
Attach 51 Pediatric Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F).pdf
Form and Instruction
52 PROMIS 29 Participant
Attach 52 PROMIS 29 - Participant.pdf
Form and Instruction
57 EtOH (Alcohol) Questionaire
Attach 57 EtOH Questionnaire.pdf
Form and Instruction
55 Text Anxiety Scale
Attach 55 Test Anxiety Scale (TAS).pdf
Form and Instruction
5 Odor Identification
Attach 5 Odor Identification Ages 3-9.pdf
Form and Instruction
7 Pain Assessment Ages 3-7
Attach 7 Pain Asssessment Proxy Ages 3-7.pdf
Form and Instruction
8 Pain Assessment Ages 8-12
Attach 8 Pain Assessment Ages 8-12.pdf
Form and Instruction
9 Pain Assessment Ages 13-17
Attach 9 Pain Assessment Ages 13-17.pdf
Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Automated Audiometry from the NIH Toolbox (AANT) Attach 1 Automated Audiometry for the NIH Toolbox (AANT).pdf Yes Yes Fillable Fileable
Form and Instruction 6 University of Penn Smell Identification Attach 6 University of Pennsylvania Smell Identification Test (UPSIT).pdf Yes Yes Fillable Fileable
Form and Instruction 3 Words in Noise Attach 3 Words-In-Noise Test (WIN).pdf Yes Yes Fillable Fileable
Form and Instruction 4 Ordor Identification Attach 4 Odor Identification Ages 10-85.pdf Yes Yes Fillable Fileable
Form and Instruction 11 Sucrose Preference Test Attach 11 Sucrose Preference Test.pdf Yes Yes Fillable Fileable
Form and Instruction 12 Toolbox Taste Test Attach 12 Toolbox Taste Test.pdf Yes Yes Fillable Fileable
Form and Instruction 13 Dynamic Visual Acuity (DVA) Attach 13 Dynamic Visual Acuity (DVA).pdf No Yes Fillable Fileable
Form and Instruction 14 Vision Health Related QOL Survey Attach 14 Vision Health-Related Quality of Life Survey.pdf Yes Yes Fillable Fileable
Form and Instruction 15 Brief Kinesthesia Test Attach 15 Brief Kinesthesia Test.pdf Yes Yes Fillable Fileable
Form and Instruction 17 Tactile Discrimination Test Attach 17 Tactile Discrimination Test.pdf Yes Yes Fillable Fileable
Form and Instruction 18 Dimensional Card Change Sort Attach 18 Dimensional Change Card Sort.pdf Yes Yes Fillable Fileable
Form and Instruction 19 Bateria III Picture Vocabulary (Spanish only) Attach 19 Bateria III Picture Vocabulary.pdf Yes Yes Fillable Fileable
Form and Instruction 20 Imitation Based Assessment of Memory Attach 20 Flanker.pdf Yes Yes Fillable Fileable
Form and Instruction 22 List Sorting Attach 22 List Sorting.pdf Yes Yes Fillable Fileable
Form and Instruction 23 Oral Symbol Digit Modalities Attach 23 Oral Symbol Digit Modalities Test.pdf Yes Yes Paper Only
Form and Instruction 24 Pattern Comparison Attach 24 Pattern Comparison.pdf Yes Yes Fillable Fileable
Form and Instruction 26 Reading Recognition Attach 26 Reading Recognition.pdf Yes Yes Fillable Fileable
Form and Instruction 27 Handedness Assessment Attach 27 Determining Handedness.pdf Yes Yes Fillable Fileable
Form and Instruction 28 Vocabulary Comprehension Attach 28 Vocabulary Comprehension.pdf Yes Yes Fillable Fileable
Form and Instruction 29 Word Accentuation (Spanish only) Attach 29 Spanish Word Accentuation Test.pdf Yes Yes Fillable Fileable
Instruction Attach 30 Instructions for Emotional Health Questionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction 31 Emotional Health Questionaire Attach 31 Emotional Health Questionnaires for Toolbox.xlsx Yes Yes Fillable Fileable
Form and Instruction 32 Supplemental Emotional Health Questionaire Attach 32 Supplemental Emotional Health Questionnaires.xls Yes Yes Fillable Fileable
Form and Instruction 33 Dexterity 9-hole Pegboard Attach 33 9 Hole Pegboard.pdf Yes Yes Fillable Fileable
Form and Instruction 34 Endurance 2-Minute Walk Test Attach 34 Endurance 2 Minute Walk Test (2MWT).pdf Yes Yes Fillable Fileable
Form and Instruction 35 Locomotion 4-meter Walk Test Attach 35 Locomotion 4 Meter Walk Test.pdf Yes Yes Fillable Fileable
Form and Instruction 36 Grip Strength Dynamometry Attach 36 Grip Strength Dynamometry.pdf Yes Yes Fillable Fileable
Form and Instruction 37 Strength Knee Extension Attach 37 Strength Knee Extension.pdf Yes Yes Fillable Fileable
Form and Instruction 38 Balance Accelerometer Measure Attach 38 Balance Accelerometer Measure (BAM).pdf Yes Yes Fillable Fileable
Form and Instruction 40 Initial Child/Proxy Questionaire Attach 40 Initial Questionnaire-Proxy and Child.pdf Yes Yes Fillable Fileable
Form and Instruction 41 Additional Somatosensation Questions Attach 41 Additional Somatosensation Questions.pdf Yes Yes Fillable Fileable
Form and Instruction 42 Additional Audition Olfaction Taste Attach 42 Additional Audition Olfaction Taste Questions.pdf Yes Yes Fillable Fileable
Form and Instruction 47 Pediatric Perceived Cognitive Child Attach 47 Pediatric Perceived Cognitive Function (PCF) - Child.pdf Yes Yes Fillable Fileable
Form and Instruction 49 Pediatric PROMIS Physical Function Upper Extremity Attach 49 PROMIS Pediatric Physical Function Upper Extremity.pdf Yes Yes Fillable Fileable
Form and Instruction 50 Pediatric PROMIS Physical Function Mobility Attach 50 PROMIS Pediatric Physical Function Mobility.pdf Yes Yes Fillable Fileable
Form and Instruction 51 Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue Attach 51 Pediatric Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F).pdf Yes Yes Fillable Fileable
Form and Instruction 52 PROMIS 29 Participant Attach 52 PROMIS 29 - Participant.pdf Yes Yes Fillable Fileable
Form and Instruction 57 EtOH (Alcohol) Questionaire Attach 57 EtOH Questionnaire.pdf No No Fillable Fileable
Form and Instruction 55 Text Anxiety Scale Attach 55 Test Anxiety Scale (TAS).pdf Yes Yes Fillable Fileable
Form and Instruction 5 Odor Identification Attach 5 Odor Identification Ages 3-9.pdf Yes Yes Fillable Fileable
Form and Instruction 7 Pain Assessment Ages 3-7 Attach 7 Pain Asssessment Proxy Ages 3-7.pdf Yes Yes Fillable Fileable
Form and Instruction 8 Pain Assessment Ages 8-12 Attach 8 Pain Assessment Ages 8-12.pdf Yes Yes Fillable Fileable
Form and Instruction 9 Pain Assessment Ages 13-17 Attach 9 Pain Assessment Ages 13-17.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 6,750 0 6,750 0 0 0
Annual IC Time Burden (Hours) 16,875 0 16,875 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.