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 26.2 Survey Form and Instruction New Available
Form 26.4 Survey - Placeholder for copyrighted material Form and Instruction New Available
Form 26.3 Survey - Placeholder for copyrighted material Form and Instruction New Available
Form 26.1 Survey Form and Instruction New Available
Form 25.1 Survey Form and Instruction New Available
Form 20.1 Survey Form and Instruction New Available
Form 19.1 Survey Form and Instruction New Available
Form 16.4 Survey Form and Instruction New Available
Form 16.3 Survey Form and Instruction New Available
Form 16.5 Survey Form and Instruction New Available
Form 16.1 Survey Form and Instruction New Available
Form 16.2 Survey Form and Instruction New Available
Form 6.1 Survey Form and Instruction New Available
Form 5.1 Survey Form and Instruction New Available
Form 3.1 Survey Form and Instruction New Available
Form 2.4 Survey Form and Instruction New Available
Form 2.2 Survey Form and Instruction New Available
Form 2.1 Survey Form and Instruction New Available
Form 2.3 Survey Form and Instruction New Available
Form 1.1 Survey Form and Instruction New Available
Form 24.5 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 24.3 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 24.2 Survey Form and Instruction Modified Available
Form 24.1 Survey Form and Instruction Modified Available
Form 24.4 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.6 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.5 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.3 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.2 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.4 Survey - Placeholder for copyrighted material Form and Instruction Modified Available
Form 23.1 Survey Form and Instruction Modified Available
Form 22.3 Survey - Placeholder for Copyrighted Material Form and Instruction Modified Available
Form 22.2 Survey Form and Instruction Modified Available
Form 22.1 Survey Form and Instruction Modified Available
Form 21.1 Survey Form and Instruction Modified Available
Form 18.2 Survey Form and Instruction Modified Available
Form 18.1 Survey Form and Instruction Modified Available
Form 24.1 Survey Form and Instruction Modified Available
Form 23.1 Survey Form and Instruction Removed Available
Form 15.1 Log Form and Instruction Modified Available
Form 14.1 Survey Form and Instruction Modified Available
Form 13.1 Survey Form and Instruction Modified Available
Form 12.1 Survey Form and Instruction Modified Available
Form 18.1 Consent Form and Instruction Removed Available
Form 11.1 Log Form and Instruction Modified Available
Form 9.2 Survey Form and Instruction Modified Available
Form 9.1 Survey Form and Instruction Modified Available
Form 8.2 Survey Form and Instruction Modified Available
Form 8.1 Survey Form and Instruction Modified Available
Form 14.1 Consent Form and Instruction Removed Available
Form 4.1 Survey Form and Instruction Modified Available
Form 7.1 Survey Form and Instruction Modified Available
Form 11.2 Survey Form and Instruction Removed Available
Form 11.1 Survey Form and Instruction Removed Available
Form 10.2 Survey Form and Instruction Modified Available
Form 10.1 Survey Form and Instruction Modified Available
Form 10.4 Survey Form and Instruction Modified Available
Form 10.3 Survey Form and Instruction Modified Available
Form 9.2 Survey Form and Instruction Removed Available
Form 9.1 Survey Form and Instruction Removed Available
Form 8.1 Consent Form and Instruction Removed Available
Form 7.1 Consent Form and Instruction Removed Available
Form 6.1 Survey Form and Instruction Removed Available
Form 5.1 Survey Form and Instruction Removed Available
Form 4.1 Survey Form and Instruction Removed Available
Form 3.1 Survey Form and Instruction Removed Available
Form 2.3 Survey Form and Instruction Removed Available
Form 2.2 Survey Form and Instruction Removed Available
Form 2.1 Survey 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 NewSurvey
202215 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey - Placeholder for copyrighted material
202215 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey - Placeholder for copyrighted material
202215 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey
202214 Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey
202213 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction NewSurvey
202212 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction NewSurvey
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction NewSurvey
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction NewSurvey
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction NewSurvey
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction NewSurvey
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction NewSurvey
202210 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey
202209 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction NewSurvey
202208 Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction NewSurvey
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction NewSurvey
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction NewSurvey
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction NewSurvey
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction NewSurvey
202206 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction NewSurvey
193580 Formative - Developmental Instruction Modified
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193579 24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey - Placeholder for copyrighted material
193578 18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193577 12-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey - Placeholder for Copyrighted Material
193577 12-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193577 12-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193576 9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193575 6-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193575 6-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193574 3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193573 Low-Intensity Questionnaire (Child-focus) (TT-LI) Form and Instruction RemovedSurvey
193572 Infant Feeding Log (PB, EH, TT-HI, PBS) Form and Instruction ModifiedLog
193571 Low-Intensity Questionnaire (Birth focus) (TT-LI) Form and Instruction ModifiedSurvey
193570 Birth Visit Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193569 Father Interview (PB, EH, TT-HI) Form and Instruction ModifiedSurvey
193568 Father Informed Consent Form (PB, EH, TT-HI) Form and Instruction RemovedConsent
193567 Pregnancy Health Care Log (PB, EH, TT-HI, PBS) Form and Instruction ModifiedLog
193566 Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193566 Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193565 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193565 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193564 Pregnant Women's Informed Consent Form (PB, EH, TT-HI) Form and Instruction RemovedConsent
193563 Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction ModifiedSurvey
193562 Low-Intensity Questionnaire (Found Pregnant) (TT-LI) Form and Instruction ModifiedSurvey
193561 Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) Form and Instruction RemovedSurvey
193561 Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) Form and Instruction RemovedSurvey
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction ModifiedSurvey
193559 Pre-Pregnancy Interview (PB, EH, TT-HI) Form and Instruction RemovedSurvey
193559 Pre-Pregnancy Interview (PB, EH, TT-HI) Form and Instruction RemovedSurvey
193558 Non-pregnant Women's Informed Consent (PB, EH, TT-HI) Form and Instruction RemovedConsent
193557 Low-Intensity Consent Script (TT-LI) Form and Instruction RemovedConsent
193556 Pregnancy Screener (TT-LI, TT-HI) Form and Instruction RemovedSurvey
193555 Low-Intensity Invitation to High-Intensity Script (TT-HI) Form and Instruction RemovedSurvey
193554 Household Enumeration Instrument (EH) Form and Instruction RemovedSurvey
193553 Healthcare Provider Questionnaire (PB) Form and Instruction RemovedSurvey
184272 Pregnancy Screener (PB, EH, TT-HI) Form and Instruction RemovedSurvey
184272 Pregnancy Screener (PB, EH, TT-HI) Form and Instruction RemovedSurvey
184272 Pregnancy Screener (PB, EH, TT-HI) Form and Instruction RemovedSurvey
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
12-Month Interview (PB, EH, TT-HI, PBS) 22.1, 22.2, 22.3 ,   ,  
18-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 23.1, 23.4, 23.2, 23.3, 23.5, 23.6 ,   ,   ,   ,   ,  
24-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 24.1, 24.2, 24.3, 24.4, 24.5 ,   ,   ,   ,  
3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 24.1
30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 26.2, 26.1, 26.3, 26.4 ,   ,   ,  
6-Month Interview (PB, EH, TT-HI, PBS) 18.1, 18.2 ,  
9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) 21.1
Address Lookup Tool (PB)
Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) 10.3, 10.4, 10.1, 10.2 ,   ,   ,  
Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) 16.2, 16.1, 16.5, 16.3, 16.4 ,   ,   ,   ,  
Birth Visit Interview (PB, EH, TT-HI, PBS) 13.1
Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) 25.1
Father Informed Consent Form (PB, EH, TT-HI) 18.1
Father Interview (PB, EH, TT-HI) 12.1
Formative - Developmental
Healthcare Provider Questionnaire (PB) 3.1
Household Enumeration Instrument (EH) 4.1
Infant Feeding Log (PB, EH, TT-HI, PBS) 15.1
Low-Intensity Consent Script (TT-LI) 7.1
Low-Intensity Invitation to High-Intensity Script (TT-HI) 5.1
Low-Intensity Questionnaire (Birth focus) (TT-LI) 14.1
Low-Intensity Questionnaire (Child-focus) (TT-LI) 23.1
Low-Intensity Questionnaire (Found Pregnant) (TT-LI) 7.1
Non-pregnant Women's Informed Consent (PB, EH, TT-HI) 8.1
Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) 3.1
Participant Verification (PB, EH, TT-HI, TT-HI, PBS) 5.1
Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) 19.1
Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) 20.1
Pre-Pregnancy Interview (PB, EH, TT-HI) 9.1, 9.2 ,  
Pregnancy Health Care Log (PB, EH, TT-HI, PBS) 11.1
Pregnancy Probability Group Follow Up Script (PB, EH, TT-HI, TT-LI) 11.1, 11.2 ,  
Pregnancy Screener (PB, EH, TT-HI) 2.1, 2.2, 2.3 ,   ,  
Pregnancy Screener (TT-LI, TT-HI) 6.1
Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) 8.1, 8.2 ,  
Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) 9.1, 9.2 ,  
Pregnant Women's Informed Consent Form (PB, EH, TT-HI) 14.1
Provider-Based Sampling Eligibility Screener (PBS) 1.1
Provider-Based Sampling Frame Questionnaire (PBS) 2.3, 2.1, 2.2, 2.4 ,   ,   ,  
Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) 6.1
Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) 4.1

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