Information Collection

Assessment of Executive Function for the National Children's Study

IC 212511 under ICR 201206-0925-004 · OMB 0925-0661.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0661 can be found here:

2014-12-03 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form 1 Assessment of Executive Function for the National Children's Study Form and Instruction
Attach 17 Consent Form Delve with no 2nd session.docx Other-Consent
Attach 19 Consent Form UofM with no 2nd session.docx Other-Consent
Attach 26 Child Assent Form.docx Other-Assent
Attach 16 Consent Form Delve with 2nd session.docx Other-Consent 2
Attach 18 Consent Form UofM with 2nd session.docx Other-Consent 2
Attach 26 Child Assent Form.docx Other-Consent 2
1 Recruitment Screening Interview Attach 15 Recruitment Screening Script.docx Form and Instruction
2 Family Demographic Questionnaire Attach 9 Family Demographic Questionnaire_FINAL.docx Form and Instruction
3 CBQ-VSF+EF Attach 10 CBQ-VSF+EF.docx Form and Instruction
4 Ages and Stages Social Emotional Questionnaire Attach 11 Ages and Stages Social Emotional Questionanaire.docx Form and Instruction
5 Strengths and Difficulties Questionnaire Attach 12 Strengths and Difficulties Questionnaire.docx Form and Instruction
6 Q-ABC Attach 13 Q-ABC.docx Form and Instruction
7 Touch Screen Tutorial Attach 1 Touch Screen Tutorial.docx Form and Instruction
8 Dimensional Change Card Sort Test Attach 2 Dimensional Change Card Sort Test.docx Form and Instruction
9 Flanker Inhibitory Control and Attention Test Attach 3 Flanker Inhibitory Control and Attention Test.docx Form and Instruction
10 Picture Vocabulary Test Attach 4 Picture Vocabulary Test.docx Form and Instruction
11 Picture Sequence Memory Test Attach 5 Picture Sequence Memory Test.docx Form and Instruction
12 Peg Tapping Attach 6 Peg Tapping.docx Form and Instruction
13 WPPSI-IV Block Design Attach 7 WPPSI-IV Block Design.docx Form and Instruction
12 Woodcock-Johnson III Tests of Achievement Attach 8 Woodcock Johnson III.docx Form and Instruction
Attach 14 Letter of Invitation.docx Letter of Invitation IC Document
Attach 20 Univ of Minnesota IRB Original Application 01052011.pdf Univ of Minnesota IRB Original Application 01052011 IC Document
Attach 21 Univ of Minnesota IRB Annual Renewal Approval 03062014.pdf Univ of Minnesota IRB Annual Renewal Approval 03062014 IC Document
Attach 22 Univ of Minnesota IRB Change in Protocol Request 11062013.docx Univ of Minnesota IRB Change in Protocol Request 11062013 IC Document
Attach 23 Univ of Minnesota IRB Change in Protocol Approval 11132013.pdf Univ of Minnesota IRB Change in Protocol Approval 11132013 IC Document
Attach 24 Delve IRB Letter.pdf Delve IRB Letter IC Document
Attach 25 Northwestern Univ IRB Letter.pdf Northwestern Univ IRB Letter IC Document
Attach 27 Univ of Minnesota IRB Change in Protocol Approval 06062014.pdf Univ of Minnesota IRB Change in Protocol Approval 06062014 IC Document
Executive_Function_LOI2-QUEX-6_OIRA_Template_FINAL Nov 2014.docx OMB Request Template IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Assessment of Executive Function for the National Children's Study	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Recruitment Screening Interview	Attach 15 Recruitment Screening Script.docx	Yes	Yes	Fillable Fileable
Other-Consent			Attach 17 Consent Form Delve with no 2nd session.docx	Yes	Yes	Fillable Fileable Signable
Other-Consent			Attach 19 Consent Form UofM with no 2nd session.docx	Yes	Yes	Fillable Fileable Signable
Other-Assent			Attach 26 Child Assent Form.docx	Yes	Yes	Fillable Fileable Signable
Form and Instruction	2	Family Demographic Questionnaire	Attach 9 Family Demographic Questionnaire_FINAL.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	CBQ-VSF+EF	Attach 10 CBQ-VSF+EF.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Ages and Stages Social Emotional Questionnaire	Attach 11 Ages and Stages Social Emotional Questionanaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Strengths and Difficulties Questionnaire	Attach 12 Strengths and Difficulties Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	Q-ABC	Attach 13 Q-ABC.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7	Touch Screen Tutorial	Attach 1 Touch Screen Tutorial.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8	Dimensional Change Card Sort Test	Attach 2 Dimensional Change Card Sort Test.docx	Yes	Yes	Fillable Fileable
Form and Instruction	9	Flanker Inhibitory Control and Attention Test	Attach 3 Flanker Inhibitory Control and Attention Test.docx	Yes	Yes	Fillable Fileable
Form and Instruction	10	Picture Vocabulary Test	Attach 4 Picture Vocabulary Test.docx	Yes	Yes	Fillable Fileable
Form and Instruction	11	Picture Sequence Memory Test	Attach 5 Picture Sequence Memory Test.docx	Yes	Yes	Fillable Fileable
Form and Instruction	12	Peg Tapping	Attach 6 Peg Tapping.docx	Yes	Yes	Fillable Fileable
Form and Instruction	13	WPPSI-IV Block Design	Attach 7 WPPSI-IV Block Design.docx	Yes	Yes	Fillable Fileable
Form and Instruction	12	Woodcock-Johnson III Tests of Achievement	Attach 8 Woodcock Johnson III.docx	Yes	Yes	Fillable Fileable
Other-Consent 2			Attach 16 Consent Form Delve with 2nd session.docx	Yes	Yes	Fillable Fileable Signable
Other-Consent 2			Attach 18 Consent Form UofM with 2nd session.docx	Yes	Yes	Fillable Fileable Signable
Other-Consent 2			Attach 26 Child Assent Form.docx	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 792	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	792	792
Annual IC Time Burden (Hours)	814	814
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation	Attach 14 Letter of Invitation.docx	07/29/2014
Univ of Minnesota IRB Original Application 01052011	Attach 20 Univ of Minnesota IRB Original Application 01052011.pdf	07/29/2014
Univ of Minnesota IRB Annual Renewal Approval 03062014	Attach 21 Univ of Minnesota IRB Annual Renewal Approval 03062014.pdf	07/29/2014
Univ of Minnesota IRB Change in Protocol Request 11062013	Attach 22 Univ of Minnesota IRB Change in Protocol Request 11062013.docx	07/29/2014
Univ of Minnesota IRB Change in Protocol Approval 11132013	Attach 23 Univ of Minnesota IRB Change in Protocol Approval 11132013.pdf	07/29/2014
Delve IRB Letter	Attach 24 Delve IRB Letter.pdf	07/29/2014
Northwestern Univ IRB Letter	Attach 25 Northwestern Univ IRB Letter.pdf	07/29/2014
Univ of Minnesota IRB Change in Protocol Approval 06062014	Attach 27 Univ of Minnesota IRB Change in Protocol Approval 06062014.pdf	07/29/2014
OMB Request Template	Executive_Function_LOI2-QUEX-6_OIRA_Template_FINAL Nov 2014.docx	11/12/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.