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 201211-0925-001 · 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 Modified Available
Form 25.1 Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 20.1 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified Available
Form 19.1 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified Available
Form 16.2 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction Modified Available
Form 6.1 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 5.1 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction Modified Available
Form 3.1 Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Available
Form 2.3 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction Modified Available
Form 1.1 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction Modified Available
Form 24.3 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 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 11.1 Pregnancy Health Care Log (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 9.2 Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Form 8.3 Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified 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 10.3 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction Modified Available
Cover_Memorandum_NCS_Request_for_Nonsubstantive_Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2013-03-08 Available
List of Instruments.docx Supplementary Document Uploaded 2013-03-08 Available
Consent Documents.pdf Supplementary Document Uploaded 2013-03-08 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
Attach A17. PFQ Refusal Letter for Providers_final.docx Supplementary Document Uploaded 2013-03-09 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
Attach B1. LOI2-QUEX-14-Phase 2 OIRA Template.docx Supplementary Document Uploaded 2012-11-01 Available
Attach B14. LOI2-QUEX-14 Manual of Procedures.pdf Supplementary Document Uploaded 2012-10-19 Available
Attach B17. Vanguard Pilot Study Biospecimen Collection Chart.docx Supplementary Document Uploaded 2012-10-19 Available
Attach B15. LOI2-QUEX-14 Exemplar Recruitment Flyer.docx Supplementary Document Uploaded 2012-10-19 Available
Attach B13. LOI2-QUEX-14 IRB Approval Letters.pdf Supplementary Document Uploaded 2012-10-19 Available
Attach B2. LOI2-QUEX-14 Exemplar Consent Form.doc Supplementary Document Uploaded 2012-10-19 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
Attach A10. PLSND Telephone Reminder Call Script.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A9. PLSND Mail Reminder Call Script.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A8. PLSND Telephone Medical Records and Death Cert Release.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A7. PLSND Telephone Medical Records Release Forms Letter.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A6. PLSND Follow-Up SAQ and Release Forms Letter.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A5. PLSND Item NR Rates.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A4. PLSND Death Certificate Release Form.docx Supplementary Document Uploaded 2012-10-19 Available
Attach A3. PLSND Medical Records Release Form.docx Supplementary Document Uploaded 2012-10-19 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

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
202215 30-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
202214 Core Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
202213 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified
202212 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified
202211 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction Modified
202210 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
202209 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction Modified
202208 Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified
202207 Provider-Based Sampling Frame Questionnaire (PBS) Form and Instruction Modified
202206 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction Modified
193580 Formative - Developmental Other-Research 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
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
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
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
193560 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2014 08/31/2014 08/31/2014
55,748 0 55,748
22,791 0 22,791
0 0 0





Reginfo record details
27
table that charts list of burden
IC Title Form No. Form Name
Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) 10.3, 10.4, 10.2, 10.5, 10.6 Survey ,   Survey ,   Survey ,   Survey ,   Survey
Infant Feeding Log (PB, EH, TT-HI, PBS) 15.1 Log
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
Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) 16.2, 16.1, 16.5, 16.3, 16.4 Survey ,   Survey ,   Survey ,   Survey ,   Survey
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) 26.3, 26.1, 26.4, 26.2 Survey ,   Survey - Placeholder for copyrighted material ,   Survey - Placeholder for copyrighted material ,   Survey
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
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 - Placeholder for copyrighted material ,   Survey ,   Survey
Formative - Developmental none, 17.1, 17.2, 17.3, 17.4, 17.5, 17.6, 17.8, 17.9, 17.10, 17.11, 17.7 Attach B25. Participant Verification Birth Cohort ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey ,   Survey
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
Nonrespondent Questionnaire (PB, EH, TT-HI, TT-LI, PBS) 3.1 Survey
Participant Verification (PB, EH, TT-HI, TT-HI, PBS) 5.1 Survey
Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) 6.1 Survey
Pregnancy Visit 1 Interview (PB, EH, TT-HI, PBS) 8.3, 8.4, 8.1, 8.2 Survey ,   Survey ,   Survey ,   Survey
Pregnancy Visit 2 Interview (PB, EH, TT-HI, PBS) 9.2, 9.1 Survey ,   Survey
Pregnancy Health Care Log (PB, EH, TT-HI, PBS) 11.1 Log
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

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 55,748 0 0 0 0
Annual Time Burden (Hours) 22,791 22,791 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No