App.X.1_Eng Note sheet for AMPM

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

Appendix X.1

Note Sheet for AMPM – ENGLISH

To document foods child ate/drank away from home

This note sheet is for you to use to jot down the foods your child ate or drank away from home the day before your interview. We will not ask you to return it. You will use it as a reference for the interview.

If your child is going to be at daycare the day before your interview, you may want to have the daycare person write down the foods your child ate at daycare and give it back to you when you pick up your child. 

 

What food did child drink or eat?	How much did child drink or eat?	What time did child drink or eat?
Example:
Bottle	8oz	7:30A
Baby rice cereal	4oz	11A
Baby peaches	4oz jar	11A
Bottle	8 oz	11:30A

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number.  The valid OMB control number for this information collection is 0584-XXXX.  The time required to complete this information collection is estimated to average 0.5 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.