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
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 Repair queued
Form 20.1 Physical Measures - Child Blood Pressure (12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified Repair queued
Form 19.1 Physical Measures - Child Anthropometry (6-,12-,24-Month) (PB, EH, TT-HI) Form and Instruction Modified Repair queued
Form 16.2 Biospecimen Sample Collection - Mother / Baby (PB, EH, TT-LI) Form and Instruction Modified Repair queued
Form 6.1 Tracing Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Repair queued
Form 5.1 Participant Verification (PB, EH, TT-HI, TT-HI, PBS) Form and Instruction Modified Repair queued
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 Repair queued
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 Repair queued
Form 21.1 9-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Repair queued
Form 18.1 6-Month Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Repair queued
Form 24.1 3-Month Interview (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Repair queued
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 Repair queued
Form 13.1 Birth Visit Interview (PB, EH, TT-HI, PBS) Form and Instruction Modified Repair queued
Form 12.1 Father Interview (PB, EH, TT-HI) Form and Instruction Modified Repair queued
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 Repair queued
Form 4.1 Validation Interview - up to 30 months (PB, EH, TT-HI, TT-LI, PBS) Form and Instruction Modified Repair queued
Form 7.1 Low-Intensity Questionnaire (Found Pregnant) (TT-LI) Form and Instruction Modified Repair queued
Form 10.3 Biological and Environmental Sample Collection (Prenatal) (PB, EH, TT-HI, PBS) Form and Instruction Modified Repair queued
Cover_Memorandum_NCS_Request_for_Nonsubstantive_Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2013-03-08 Repair queued
List of Instruments.docx Supplementary Document Uploaded 2013-03-08 Repair queued
Consent Documents.pdf Supplementary Document Uploaded 2013-03-08 Repair queued
12 MO Child Saliva Instructions 20120413.docx Supplementary Document Uploaded 2012-04-16 Repair queued
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 Repair queued
Provider Based Sampling Brochure.docx Supplementary Document Uploaded 2012-04-16 Repair queued
Provider Based Sampling Advance Letter to Office Manager.docx Supplementary Document Uploaded 2012-04-16 Repair queued
Exemplar Letter to Accompany Questionnaire.doc Supplementary Document Uploaded 2012-04-16 Repair queued
Advance Letter to Providers.docx Supplementary Document Uploaded 2012-04-16 Repair queued
Attach B1. LOI2-QUEX-14-Phase 2 OIRA Template.docx Supplementary Document Uploaded 2012-11-01 Repair queued
Attach B14. LOI2-QUEX-14 Manual of Procedures.pdf Supplementary Document Uploaded 2012-10-19 Repair queued
Attach B17. Vanguard Pilot Study Biospecimen Collection Chart.docx Supplementary Document Uploaded 2012-10-19 Repair queued
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 Repair queued
Birth VIS With Samples 20120413.docx Supplementary Document Uploaded 2012-04-13 Repair queued
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 Repair queued
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 Repair queued
Attach A9. PLSND Mail Reminder Call Script.docx Supplementary Document Uploaded 2012-10-19 Repair queued
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 Repair queued
Attach A6. PLSND Follow-Up SAQ and Release Forms Letter.docx Supplementary Document Uploaded 2012-10-19 Repair queued
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 Repair queued
Attach A3. PLSND Medical Records Release Form.docx Supplementary Document Uploaded 2012-10-19 Repair queued
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 Repair queued
Pre-Visit Instructions for Blood and Urine Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Repair queued
Pre-Visit Information for Non Fasting Venous Blood Adult Urine Vacuum Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Repair queued
Pre-visit Information for Fasting Blood Urine Vacuum Collection 20110211.doc Supplementary Document Uploaded 2012-04-16 Repair queued
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 Repair queued
TWQ Sample Distribution Script 20120413.docx Supplementary Document Uploaded 2012-04-13 Repair queued
TWF Sample Distribution Script 20120413.docx Supplementary Document Uploaded 2012-04-13 Repair queued
IC Document Collections
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
0925-0593 201211-0925-001
Historical Active 201205-0925-002
HHS/NIH
Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 03/09/2013
Retrieve Notice of Action (NOA) 11/06/2012
Prior terms continue. Approved consistent with the follow two terms: 1) In advance of adding biological and environmental sampling for the participants in the provider-based sampling arm of the Vanguard study, NIH will consult with the IRB amount whether the time between written consent for biosampling and the actual implementation of this activity warrents written re-consent. 2) NIH agrees to brief OMB/OIRA on the results of this test, particularly the measures in Table A.16 in advance of finalizing the design for the main study of the NCS.
  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

The National Children's Study is an integrated system of activities that includes a Vanguard (Pilot) Study for operations and methods development, and an NCS Main Study to collect data on exposure and response. The Vanguard (Pilot) Study, which includes the Initial Vanguard Study, the Alternate Recruitment Substudy (Phases 1 and 2), and the Provider-Based Sampling Feasibility Study (proposed in this information collection request), is currently underway. The Main Study is expected to follow within the next year. This request for revision includes (1) the addition of a Provider-Based Sampling Feasibility Study, and (2) supplemental measures for the Alternate Recruitment Substudy involving revised study visit assessments, physical measurements, and additional biospecimen collections. These information collections, revisions of instruments, physical measure implementation, and biospecimen collections will evaluate the feasibility, acceptability, and cost of study design elements to inform the Main Study.

PL: Pub.L. 106 - 310 1004 Name of Law: Childrens Health Act of 2000
  
None

Not associated with rulemaking

Yes

27
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

  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
No
No

$71,904,774
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Mikia Currie 3014350941

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/06/2012