Formative - Developmental

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?	Hispanic 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.