Questionnaires, Time Diary, Heart Monitoring

Stress and Cortisol Measurement for the National Childrens Study (NICHD)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0671 can be found here:

Documents and Forms

Document Name Document Type
Form 2.1 Questionnaires, Time Diary, Heart Monitoring Form and Instruction
Attach 22. Electronic Diary Coordinators Manual.doc Instruction
Attach 23. Actiheart Procedures Coordinators Manual.doc Instruction
2.1 Participant Contact Information Sheet Attach 4. Participant Contact Information Sheet.docx Form and Instruction
2.2 Demographic and Health Survey Attach 6. Demographic and Health Survey.docx Form and Instruction
2.3 Visit 1 Stress Questionnaire Attach 7.Visit 1 Stress Questionnaire.docx Form and Instruction
2.4 Take Home Packet Attach 8. Take Home Packet.docx Form and Instruction
2.5 Visit 2 Stress Questionnaire Attach 9. Visit 2 Stress Questionnaire.docx Form and Instruction
2.6 SLES Checklist Attach 10. SLES Checklist.pdf Form and Instruction
Attach 5. Enrollment Medical Record Abstraction Form.doc Enrollment Medical Record Abstraction Form IC Document
Attach 11. Postpartum Abstraction Form.doc Postpartum Abstraction Form IC Document
Note-to-File - Burden for IC #2.docx Note-to-File - Burden for IC #2 IC Document

Information Collection (IC) Details

IC Title:	Questionnaires, Time Diary, Heart Monitoring	Agency IC Tracking Number:

Is this a Common Form? No		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	2.1	Participant Contact Information Sheet	Attach 4. Participant Contact Information Sheet.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.2	Demographic and Health Survey	Attach 6. Demographic and Health Survey.docx	Yes	Yes	Paper Only
Form and Instruction	2.3	Visit 1 Stress Questionnaire	Attach 7.Visit 1 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction			Attach 22. Electronic Diary Coordinators Manual.doc	Yes	Yes	Paper Only
Form and Instruction	2.4	Take Home Packet	Attach 8. Take Home Packet.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.5	Visit 2 Stress Questionnaire	Attach 9. Visit 2 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction			Attach 23. Actiheart Procedures Coordinators Manual.doc	Yes	Yes	Paper Only
Form and Instruction	2.6	SLES Checklist	Attach 10. SLES Checklist.pdf	Yes	Yes	Fillable Printable

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: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56,000	56,000
Annual IC Time Burden (Hours)	4,736	4,736
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Enrollment Medical Record Abstraction Form	Attach 5. Enrollment Medical Record Abstraction Form.doc	07/17/2012
Postpartum Abstraction Form	Attach 11. Postpartum Abstraction Form.doc	07/17/2012
Note-to-File - Burden for IC #2	Note-to-File - Burden for IC #2.docx	07/17/2012

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