Information Collection

Formative - Developmental

IC 193580 under ICR 201109-0925-003 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Burden 19 HiLo Household Inventory Questionnaire 20110420 - LOIx-QUEX-01-B-1.DOCX	Instruction
Burden 20 Participant Internet Usage and Contact Preference Survey 20110420 - LOI2-INF-17.docx	Instruction
Burden 125 Exemplar Demographics 20110621 - LOI3-PHYS-02.docx	Instruction
Burden 250 Measurement Form 20110621 - LOI3-PHYS-02.pdf	Instruction
Burden 38 Contact Info 20110621 - LOI3-PHYS-01.docx	Instruction
Burden 38 Exit Survey 20110621 - LOI3-PHYS-01.docx	Instruction
Burden 38 Visit Screen 20110621 - LOI3-PHYS-01.docx	Instruction
Burden 75 Questionnaire 20110621 - LOI3-PHYS-01.docx	Instruction
Burden 15 Acculturation Instrument 20110621 - LOI2-QUEX-14.docx	Instruction
Burden 37 Second Acceptability Questionnaire 20110621 - LOI2-QUEX-14.doc	Instruction
Burden 38 Initial Acceptability Questionnaire 20110621 - LOI2-QUEX-14.doc	Instruction
Burden 90 Food Record 20110621 - LOI2-QUEX-14.docx	Instruction
Burden 100 NCS FFQ 20110621 - LOI2-QUEX-14.pdf	Instruction
Burden 38 Screening 20110621 - LOI3-PHYS-01.docx	Instruction
Burden 250 NCS ASA24 Protocol (Placeholder for web survey) 20110621 - LOI2-QUEX-14.docx	Instruction
Note to File - Formative Research (UPDATED 20110909).docx	Instruction
Burden 900 B.1.2 LOI3-BIO-02 Exemplar Screening Interview.docx	Instruction
Burden 900 B.1.7 LOI3-BIO-02 Exemplar Interview.docx	Instruction
Burden 225 B.2.4 LOI2-PHYS-15 Exemplar Participant Experience Survey.docx	Instruction
Burden 2800 B.3.2 LOI3-QUEX-01 Exemplar Screening Tool.docx	Instruction
Burden 2800 B.3.4 LOI3-QUEX-01 Participant Contact Information Sheet.docx	Instruction
Burden 2800 B.3.5 LOI3-QUEX-01 Enrollment Medical Record Abstraction Form.doc	Instruction
Burden 2800 B.3.6 LOI3-QUEX-01 Exemplar Demographic and Health Survey.docx	Instruction
Burden 2800 B.3.7 LOI3-QUEX-01 Visit 1 Stress Questionnaire.docx	Instruction
Burden 2800 B.3.8 LOI3-QUEX-01Take Home Packet.docx	Instruction
Burden 2800 B.3.9 LOI3-QUEX-01 Visit 2 Stress Questionnaire.docx	Instruction
Burden 2800 B.3.11 LOI3-QUEX-01 Postpartum Abstraction Form.doc	Instruction
Burden 324 B.4.3 LOI2-QUEX-5 Exemplar Telephone Screener.docx	Instruction
Burden 324 B.4.4 LOI2-QUEX-5 Assessment Description Bayley-3 Short Form.docx	Instruction
Burden 2178 B.5.2 LOI2-QUEX-13 Cognitive Interview Phone Screen Script.doc	Instruction
Burden 2178 B.5.4 LOI2-QUEX-13 Cognitive Interviewing Guide.docx	Instruction
Burden 2178 B.5.5 LOI2-QUEX-13 Interview Phone Screen Script.docx	Instruction
Burden 2178 B.5.8 LOI2-QUEX-13 Exemplar Interview.doc	Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Formative - Developmental

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Burden 2800 B.3.2 LOI3-QUEX-01 Exemplar Screening Tool.docx	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.4 LOI3-QUEX-01 Participant Contact Information Sheet.docx	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.5 LOI3-QUEX-01 Enrollment Medical Record Abstraction Form.doc	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.6 LOI3-QUEX-01 Exemplar Demographic and Health Survey.docx	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.7 LOI3-QUEX-01 Visit 1 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.8 LOI3-QUEX-01Take Home Packet.docx	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.9 LOI3-QUEX-01 Visit 2 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction	Burden 324 B.4.3 LOI2-QUEX-5 Exemplar Telephone Screener.docx	Yes	Yes	Paper Only
Instruction	Burden 324 B.4.4 LOI2-QUEX-5 Assessment Description Bayley-3 Short Form.docx	Yes	Yes	Paper Only
Instruction	Burden 2178 B.5.2 LOI2-QUEX-13 Cognitive Interview Phone Screen Script.doc	Yes	Yes	Paper Only
Instruction	Burden 2178 B.5.4 LOI2-QUEX-13 Cognitive Interviewing Guide.docx	Yes	Yes	Paper Only
Instruction	Burden 2178 B.5.5 LOI2-QUEX-13 Interview Phone Screen Script.docx	Yes	Yes	Paper Only
Instruction	Burden 2178 B.5.8 LOI2-QUEX-13 Exemplar Interview.doc	Yes	Yes	Paper Only
Instruction	Burden 2800 B.3.11 LOI3-QUEX-01 Postpartum Abstraction Form.doc	Yes	Yes	Paper Only
Instruction	Burden 19 HiLo Household Inventory Questionnaire 20110420 - LOIx-QUEX-01-B-1.DOCX	Yes	Yes	Paper Only
Instruction	Burden 20 Participant Internet Usage and Contact Preference Survey 20110420 - LOI2-INF-17.docx	Yes	Yes	Paper Only
Instruction	Burden 125 Exemplar Demographics 20110621 - LOI3-PHYS-02.docx	Yes	Yes	Paper Only
Instruction	Burden 250 Measurement Form 20110621 - LOI3-PHYS-02.pdf	Yes	Yes	Paper Only
Instruction	Burden 38 Contact Info 20110621 - LOI3-PHYS-01.docx	Yes	Yes	Paper Only
Instruction	Burden 38 Exit Survey 20110621 - LOI3-PHYS-01.docx	Yes	Yes	Paper Only
Instruction	Burden 38 Visit Screen 20110621 - LOI3-PHYS-01.docx	Yes	Yes	Paper Only
Instruction	Burden 75 Questionnaire 20110621 - LOI3-PHYS-01.docx	Yes	Yes	Paper Only
Instruction	Burden 15 Acculturation Instrument 20110621 - LOI2-QUEX-14.docx	Yes	Yes	Paper Only
Instruction	Burden 37 Second Acceptability Questionnaire 20110621 - LOI2-QUEX-14.doc	Yes	Yes	Paper Only
Instruction	Burden 38 Initial Acceptability Questionnaire 20110621 - LOI2-QUEX-14.doc	Yes	Yes	Paper Only
Instruction	Burden 90 Food Record 20110621 - LOI2-QUEX-14.docx	Yes	Yes	Paper Only
Instruction	Burden 100 NCS FFQ 20110621 - LOI2-QUEX-14.pdf	Yes	Yes	Paper Only
Instruction	Burden 38 Screening 20110621 - LOI3-PHYS-01.docx	Yes	Yes	Paper Only
Instruction	Burden 250 NCS ASA24 Protocol (Placeholder for web survey) 20110621 - LOI2-QUEX-14.docx	Yes	Yes	Paper Only
Instruction	Note to File - Formative Research (UPDATED 20110909).docx	Yes	Yes	Paper Only
Instruction	Burden 900 B.1.2 LOI3-BIO-02 Exemplar Screening Interview.docx	Yes	Yes	Paper Only
Instruction	Burden 900 B.1.7 LOI3-BIO-02 Exemplar Interview.docx	Yes	Yes	Paper Only
Instruction	Burden 225 B.2.4 LOI2-PHYS-15 Exemplar Participant Experience Survey.docx	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,542

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	14,542	14,542
Annual IC Time Burden (Hours)	14,542	14,542
Annual IC Cost Burden (Dollars)	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.