Information Collection Request

Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)

ICR 201205-0925-002 · OMB 0925-0593 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 26.1 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New Available
Form 25.1 Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New Available
Form 20.1 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction New Available
Form 19.1 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction New Available
Form 16.2 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction New Available
Form 6.1 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New Available
Form 5.1 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction New Available
Form 3.1 Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New Available
Form 2.3 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction New Available
Form 1.1 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction New Available
Form 24.4 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 23.1 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 22.1 12-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 21.1 9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 18.1 6-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 24.1 3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 23.1 Low-Intensity Questionnaire (Child-focus) (TT-LI) Form and Instruction Removed Available
Form 15.1 Infant Feeding Log (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 14.1 Low-Intensity Questionnaire (Birth focus) (TT-LI) Form and Instruction Modified Available
Form 13.1 Birth Visit Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 12.1 Father Interview (PB, EH, TT-HI) Form and Instruction Modified Available
Form 18.1 Father Informed Consent Form (PB, EH, TT-HI) Form and Instruction Removed Available
Form 11.1 Pregnancy Health Care Log (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 9.1 Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 8.1 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 14.1 Pregnant Women's Informed Consent Form (PB, EH, TT-HI) Form and Instruction Removed Available
Form 4.1 Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 7.1 Low-Intensity Questionnaire (Found Pregnant) (TT-LI) Form and Instruction Modified Available
Form 11.1 Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) Form and Instruction Removed Available
Form 10.3 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 9.1 Pre-Pregnancy Interview (PB, EH, TT-HI) Form and Instruction Removed Available
Form 8.1 Non-pregnant Women's Informed Consent (PB, EH, TT-HI) Form and Instruction Removed Available
Form 7.1 Low-Intensity Consent Script (TT-LI) Form and Instruction Removed Available
Form 6.1 Pregnancy Screener (TT-LI, TT-HI) Form and Instruction Removed Available
Form 5.1 Low-Intensity Invitation to High-Intensity Script (TT-HI) Form and Instruction Removed Available
Form 4.1 Household Enumeration Instrument (EH) Form and Instruction Removed Available
Form 3.1 Healthcare Provider Questionnaire (PB) Form and Instruction Removed Available
Form 2.1 Pregnancy Screener (PB, EH, TT-HI) Form and Instruction Removed Available
PBS-SDM 2012-05 Provider Substitution Guidelines.docx Supplementary Document Uploaded 2012-08-17 Available
PBS-FSM 2012-04 Patient Recruitment Methods and Scenarios.docx Supplementary Document Uploaded 2012-08-17 Available
NCS-FS_PBS Provider Substitution Form_2012-07-06.pdf Supplementary Document Uploaded 2012-08-17 Available
Checklist for Negotiating Logistics with Providers for the NCS.docx Supplementary Document Uploaded 2012-08-17 Available
Appendix 1 - Methods for Sampling Women within Selected Providers.xlsx Supplementary Document Uploaded 2012-08-17 Available
Provider-Based Sampling Arm Supporting Statement B FINAL 20120817.docx Supporting Statement B Uploaded 2012-08-17 Available
List of Instruments 20120416.docx Supplementary Document Uploaded 2012-04-17 Available
Consent Documents.pdf Supplementary Document Uploaded 2012-04-17 Available
Itemized Burden Table.docx Supplementary Document Uploaded 2012-04-16 Available
NCS Certificate of Confidentiality.pdf Supplementary Document Uploaded 2012-04-16 Available
12 MO Child Saliva Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
6, 12 MO Child Urine Collection Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
1, 3 MO Breast Milk Collection Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
12 MO Child Saliva Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
6, 12 MO Child Urine Collection Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
1, 3 MO Breast Milk Collection Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Available
Provider Based Sampling Provider List Revision Letter.doc Supplementary Document Uploaded 2012-04-16 Available
Provider Based Sampling Brochure.docx Supplementary Document Uploaded 2012-04-16 Available
Provider Based Sampling Advance Letter to Office Manager.docx Supplementary Document Uploaded 2012-04-16 Available
Exemplar Letter to Accompany Questionnaire.doc Supplementary Document Uploaded 2012-04-16 Available
Advance Letter to Providers.docx Supplementary Document Uploaded 2012-04-16 Available
Note to File - 24 Month -- Administration of Ages and Stages 3 Questionnaire.docx Supplementary Document Uploaded 2012-04-16 Available
Note to File - 18 Month -- Administration of Ages and Stages 3 Questionnaire.docx Supplementary Document Uploaded 2012-04-16 Available
Birth Visit VIS No Sample Collection 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
Birth VIS With Samples 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
Note to File - Birth Visit - Umbilical Cord Blood Collection.docx Supplementary Document Uploaded 2011-04-08 Available
Father Visit Information Sheet 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
Pregnancy Visit 2 Visit Information Sheet.docx Supplementary Document Uploaded 2012-04-13 Available
Pregnancy Visit 1 Visit Information Sheet.docx Supplementary Document Uploaded 2012-04-13 Available
Vacuum Bag Participant Instructions 20110211.doc Supplementary Document Uploaded 2012-04-17 Available
Urine Collection Instructions 20110211.doc Supplementary Document Uploaded 2012-04-17 Available
Pre-Visit Instructions for Blood and Urine Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Available
Pre-Visit Information for Non Fasting Venous Blood Adult Urine Vacuum Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Available
Pre-visit Information for Fasting Blood Urine Vacuum Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Available
Note to File - Biological and Environmental Sample Collection (Prenatal).docx Supplementary Document Uploaded 2012-04-13 Available
VBD Sample Distribution Script 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
TWQ Sample Distribution Script 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
TWF Sample Distribution Script 20120413.docx Supplementary Document Uploaded 2012-04-13 Available
Provider-Based Sampling Arm Supporting Statement A FINAL 20120817.docx Supporting Statement A Uploaded 2012-08-17 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
202215 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New
202214 Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New
202213 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction New
202212 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction New
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction New
202210 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New
202209 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction New
202208 Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction New
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction New
202206 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction New
193580 Formative - Developmental Instruction Modified
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
193577 12-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified
193576 9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
193575 6-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified
193574 3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
193573 Low-Intensity Questionnaire (Child-focus) (TT-LI) Form and Instruction Removed
193572 Infant Feeding Log (PB, EH, TT-HI, PBS) Form and Instruction Modified
193571 Low-Intensity Questionnaire (Birth focus) (TT-LI) Form and Instruction Modified
193570 Birth Visit Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified
193569 Father Interview (PB, EH, TT-HI) Form and Instruction Modified
193568 Father Informed Consent Form (PB, EH, TT-HI) Form and Instruction Removed
193567 Pregnancy Health Care Log (PB, EH, TT-HI, PBS) Form and Instruction Modified
193566 Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified
193565 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified
193564 Pregnant Women's Informed Consent Form (PB, EH, TT-HI) Form and Instruction Removed
193563 Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
193562 Low-Intensity Questionnaire (Found Pregnant) (TT-LI) Form and Instruction Modified
193561 Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) Form and Instruction Removed
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction Modified
193559 Pre-Pregnancy Interview (PB, EH, TT-HI) Form and Instruction Removed
193558 Non-pregnant Women's Informed Consent (PB, EH, TT-HI) Form and Instruction Removed
193557 Low-Intensity Consent Script (TT-LI) Form and Instruction Removed
193556 Pregnancy Screener (TT-LI, TT-HI) Form and Instruction Removed
193555 Low-Intensity Invitation to High-Intensity Script (TT-HI) Form and Instruction Removed
193554 Household Enumeration Instrument (EH) Form and Instruction Removed
193553 Healthcare Provider Questionnaire (PB) Form and Instruction Removed
184272 Pregnancy Screener (PB, EH, TT-HI) Form and Instruction Removed
184271 Address Lookup Tool (PB) Instruction Removed

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2014 36 Months From Approved 07/31/2013
55,748 0 455,206
22,791 0 159,966
0 0 0





Reginfo record details
27
table that charts list of burden
IC Title Form No. Form Name
Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) 8.1, 8.2 Survey ,   Survey
Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) 9.1, 9.2 Survey ,   Survey
Pregnancy Health Care Log (PB, EH, TT-HI, PBS) 11.1 Log
Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) 10.3, 10.4, 10.1, 10.2 Survey ,   Survey ,   Survey ,   Survey
Low-Intensity Questionnaire (Found Pregnant) (TT-LI) 7.1 Survey
Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) 4.1 Survey
Father Interview (PB, EH, TT-HI) 12.1 Survey
Birth Visit Interview (PB, EH, TT-HI, PBS) 13.1 Survey
Low-Intensity Questionnaire (Birth focus) (TT-LI) 14.1 Survey
Infant Feeding Log (PB, EH, TT-HI, PBS) 15.1 Log
3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 24.1 Survey
6-Month Interview (PB, EH, TT-HI, PBS) 18.1, 18.2 Survey ,   Survey
9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 21.1 Survey
12-Month Interview (PB, EH, TT-HI, PBS) 22.1, 22.2, 22.3 Survey ,   Survey ,   Survey - Placeholder for Copyrighted Material
18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 23.1, 23.4, 23.2, 23.3, 23.5, 23.6 Survey ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material
Pregnancy Screener (TT-LI, TT-HI) 6.1 Survey
Low-Intensity Consent Script (TT-LI) 7.1 Consent
Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) 19.1 Survey
Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) 20.1 Survey
Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) 25.1 Survey
30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 26.2, 26.1, 26.3, 26.4 Survey ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey
Pregnancy Screener (PB, EH, TT-HI) 2.1, 2.2, 2.3 Survey ,   Survey ,   Survey
Healthcare Provider Questionnaire (PB) 3.1 Survey
Household Enumeration Instrument (EH) 4.1 Survey
Low-Intensity Invitation to High-Intensity Script (TT-HI) 5.1 Survey
Address Lookup Tool (PB)
Non-pregnant Women's Informed Consent (PB, EH, TT-HI) 8.1 Consent
Pre-Pregnancy Interview (PB, EH, TT-HI) 9.1, 9.2 Survey ,   Survey
Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) 11.1, 11.2 Survey ,   Survey
Pregnant Women's Informed Consent Form (PB, EH, TT-HI) 14.1 Consent
Father Informed Consent Form (PB, EH, TT-HI) 18.1 Consent
Low-Intensity Questionnaire (Child-focus) (TT-LI) 23.1 Survey
24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 24.1, 24.2, 24.3, 24.4, 24.5 Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey ,   Survey ,   Survey - Placeholder for copyrighted material
Formative - Developmental
Provider-Based Sampling Eligibility Screener (PBS) 1.1 Survey
Provider-Based Sampling Frame Questionnaire (PBS) 2.3, 2.1, 2.2, 2.4 Survey ,   Survey ,   Survey ,   Survey
Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) 6.1 Survey
Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) 3.1 Survey
Participant Verification (PB, EH, TT-HI, TT-HI, PBS) 5.1 Survey
Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) 16.2, 16.1, 16.5, 16.3, 16.4 Survey ,   Survey ,   Survey ,   Survey ,   Survey

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 55,748 455,206 0 -19,905 -379,553 0
Annual Time Burden (Hours) 22,791 159,966 0 -19,032 -118,143 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No