2.4 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Recruitment Response Form, Phase 2e

National Children’s Study

Recruitment Response Form

You may be eligible to participate in the National Children’s Study, the largest long-term, observational study of children’s health ever conducted in the United States. We would like the opportunity to discuss the Study with you.

I am interested in talking with someone about the National Children’s Study today.

I am interested, but am unavailable to discuss this today. Please contact me.

Name: ____________________________________________________________________

Best Phone Number to Reach You: _____________________________________________

Best Day and Time to Reach You: ______________________________________________

Email (optional): ____________________________________________________________

By signing below, I agree to be contacted by a representative of

the National Children’s Study.

Signature: _______________________________________________ Date: ______________

Signature of Interviewer: ___________________________________ Date: ______________

For Office Use Only: Name of Practice__________________________________________________ Scheduled Physician/Clinician________________________________________ Personnel Providing NCS Details______________________________________ NCS Representative Assigned to Follow-Up_____________________________

Public reporting burden for this collection of information is estimated to average 2 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 27892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.