Formative - Developmental

Recruitment Strategy Substudy for the National Children's Study (NICHD)

Burden 900 B.1.2 LOI3-BIO-02 Exemplar Screening Interview

Formative - Developmental

OMB: 0925-0593

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ATTACHMENT B.1.2 Exemplar Screening Interview OMB #: 0925-0593

LOI3-BIO-02 & -05 EXPIRATION DATE: 07/31/2013

BREAST MILK STUDY SCREENING INTERVIEW

Thank you for agreeing to participate in our study. I am going to begin by asking you a few questions to see if you qualify for our study and also to obtain some information about you.

What is your full name? (First, MI, Last): _________________________________________________________


S1. How old are you?

___________ years


S2. What is your date of birth?


_______/_______/_________

MM DD YYYY

S3. How would you describe your ethnicity?


  1. Hispanic

  2. Non-Hispanic

-1. Refused

-2. Don’t know

S4. How would you describe your ethnicity?


1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or other Pacific Islander

6. Multi-racial

-1. Refused

-2. Don’t know

S5. Do you plan to move out of the area within the next 6 months?

1.Yes

2.No

-1. Refused

-2. Don’t know

S6. Will you be travelling in the next 6 months?


1.Yes

2.No

-1. Refused

-2. Don’t know

If yes, ask further about travel to identify if the subject will be available to provide samples at one, two, and four months.


S7. Have you ever worked on a farm or with fresh fruits and/or vegetables?


1.Yes

2.No

-1. Refused

-2. Don’t know

If yes, obtain dates of employment and specific activities: _____________________________________

_________________________________________________________________________________________


IF THE MOTHER SPEAKS EITHER ENGLISH OR SPANISH, IS AT LEAST 18 YEARS OF AGE, AND WILL BE IN THE AREA FOR THE NEXT 4 MONTHS, SHE MAY PARTICIPATE IN THE STUDY. CONTINUE WITH ENROLLMENT. IF NO, THANK HER FOR HER TIME.

Public reporting burden for this collection of information is estimated to average 2 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 (0925-0593). Do not return the completed form to this address.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWendy N. Nembhard
File Modified0000-00-00
File Created2021-01-31

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