34.3 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

DietaryFoodFrequencySAQ

42-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Dietary Food Frequency SAQ, Phase 2g

OMB Specification


Dietary Food Frequency SAQ


Event Category:

Time-Based

Event:

42M, 54M

Administration:

N/A

Instrument Target:

Child

Instrument Respondent:

Primary Caregiver

Domain:

Questionnaire

Document Category:

Questionnaire

Method:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI;
Web-Based, CAI

Estimated Administration Time:

10 minutes

Multiple Child/Sibling Consideration:

Per Child

Special Considerations:

N/A

Version:

1.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.


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Dietary Food Frequency SAQ



TABLE OF CONTENTS





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Dietary Food Frequency SAQ



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER



  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





DIETARY FOOD FREQUENCY SAQ


DFF01000. This questionnaire asks about the foods your child has eaten in the past month.  Put an X in the box next to your answer. If you make any changes, cross out the incorrect answer and put an X in the box next to the correct answer. 
Answer each question as best you can.  Estimate if you are not sure -- a guess is better than leaving a blank.  Use only a black ball-point pen.  Do not use a pencil or felt-tip pen.  Please do not fold, staple, or tear the pages.  


DFF02000. ​Before you begin, please fill in today’s date


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_DATE_MM) |___|___|

   M    M


(FFQ_DATE_DD) |___|___|

   D    D


(FFQ_DATE_YY) 20|___|___|

Y Y   Y    Y



FRUITS


FRU03000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU04000/(FFQ_FRUITS_ORANGE). Orange


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU05000/(FFQ_FRUITS_GRAPEFRUIT). Grapefruit


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU06000/(FFQ_FRUITS_BANANA). Banana


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU07000/(FFQ_FRUITS_APPLE). Apple


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU08000/(FFQ_FRUITS_APPLESAUCE). Applesauce


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU09000/(FFQ_FRUITS_GRAPES). Grapes


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU10000/(FFQ_FRUITS_PEACH). Peach or plum


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU11000/(FFQ_FRUITS_BERRIES). Strawberries or other berries


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU12000/(FFQ_FRUITS_CANTALOUPE). Cantaloupe


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU13000/(FFQ_FRUITS_WATERMELON). Watermelon


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU14000/(FFQ_FRUITS_PEARS). Pears


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


FRU15000/(FFQ_FRUITS_PRUNES). Raisins or prunes


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



VEGETABLES


VEG01000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG02000/(FFQ_VEG_CORN). Corn


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG03000/(FFQ_VEG_PEAS). Peas


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG04000/(FFQ_VEG_TOMATOES). Tomatoes


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG05000/(FFQ_VEG_PEPPERS). Peppers (all kinds)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG06000/(FFQ_VEG_CARROTS). Carrots


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG07000/(FFQ_VEG_BROCCOLI). Broccoli


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG08000/(FFQ_VEG_GBEANS). Green beans


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG09000/(FFQ_VEG_SPINACH). Sprinach


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG10000/(FFQ_VEG_SQUASH). Squash (orange or winter)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG11000/(FFQ_VEG_FF). French fries, fried potatoes


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG12000/(FFQ_VEG_POTATOES). Potatoes (baked, boiled, or mashed)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


VEG13000/(FFQ_VEG_ONION). Onion


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG14000/(FFQ_VEG_YAMS). Sweet potatoes or yams


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG15000/(FFQ_VEG_CABBAGE). Cabbage, coleslaw, or cauliflower


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG16000/(FFQ_VEG_CUCUMBERS). Cucumbers


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


VEG17000/(FFQ_VEG_LETTUCE). Lettuce salad


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG18000/(FFQ_VEG_MIXED). Mixed vegetables


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG19000/(FFQ_VEG_BEANS). Baked beans or chili beans


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


VEG20000/(FFQ_VEG_OTH_BEANS). Other dried beans, dried peas or lima bean​


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



MEATS, FISH, AND OTHER MAIN DISHES


MFA00100. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month​.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA01000/(FFQ_MAIN_PIZZA). Pizza


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA02000/(FFQ_MAIN_MAC). ​Macaroni and cheese


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA03000/(FFQ_MAIN_PB). ​Peanut butter


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA04000/(FFQ_MAIN_BURGER). Hamburger, meatballs, or meatloaf


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA05000/(FFQ_MAIN_BEEF). Beef – steak or roast


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA06000/(FFQ_MAIN_PORK). Pork – chops, roast, or ribs


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA07000/(FFQ_MAIN_HAM). ​Ham – baked or steak


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA08000/(FFQ_MAIN_COLDCUTS). ​Cold cuts  (bologna, salami, ham)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA09000/(FFQ_MAIN_SAUSAGE). ​Sausage


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA10000/(FFQ_MAIN_BACON). Bacon


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA11000/(FFQ_MAIN_DOGS). Hot dogs


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA12000/(FFQ_MAIN_FRIED_CHICK). ​Fried chicken, chicken nuggets


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA13000/(FFQ_MAIN_CHICK_TURKEY). ​Other chicken or turkey


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA14000/(FFQ_MAIN_CAN_TUNA). ​Canned tuna


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA15000/(FFQ_MAIN_FRIED_FISH). ​Fried fish, fish sticks


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA16000/(FFQ_MAIN_OTH_FISH). ​Other fish


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA17000/(FFQ_MAIN_TOFU_BEANS). ​Tofu or soy beans


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA18000/(FFQ_MAIN_VEG_SOUP). ​Vegetable soup


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


MFA19000/(FFQ_MAIN_OTH_SOUP). Other soup


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



STARCHES AND GRAINS


SAG01000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG02000/(FFQ_GRAIN_PASTA). Pasta


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG03000/(FFQ_GRAIN_WHITE_RICE). White rice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG04000/(FFQ_GRAIN_BWN_RICE). Brown rice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG05000/(FFQ_GRAIN_WHITE_BREAD). ​White bread  (slice, roll, or pita)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG06000/(FFQ_GRAIN_DARK_BREAD). ​Dark bread  (slice, roll, or pita)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG07000/(FFQ_GRAIN_CORNBREAD). ​Cornbread or tortilla


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG08000/(FFQ_GRAIN_OATMEAL). ​Oatmeal


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG09000/(FFQ_GRAIN_CEREAL). ​Cereal (cold)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG10000/(FFQ_GRAIN_DONUT). ​Donut, fried dough


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG11000/(FFQ_GRAIN_MUFFIN). Sweet roll or muffin


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG12000/(FFQ_GRAIN_PANCAKE). Pancake, waffle, or French toast


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG13000/(FFQ_GRAIN_BAGEL). English muffin or bagel


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAG14000/(FFQ_GRAIN_BISCUIT). Biscuit


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



DRINKS


DRI01000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI02000/(FFQ_DRINK_MILK). ​Milk, including chocolate milk


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI03000/(FFQ_DRINK_HOT_CHOC). Hot chocolate


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI04000/(FFQ_DRINK_AJ). Apple juice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


DRI05000/(FFQ_DRINK_GJ). Grape juice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


DRI06000/(FFQ_DRINK_OJ). Orange juice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI07000/(FFQ_DRINK_PINEAPPLE). Pineapple juice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


DRI08000/(FFQ_DRINK_OTH_JUICE). ​Other 100% juice


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI09000/(FFQ_DRINK_FRUIT). ​Fruit drinks (Hi-C, Kool-Aid, lemonade)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI10000/(FFQ_DRINK_SODA). ​Soda (not sugar free)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI11000/(FFQ_DRINK_SF_SODA). ​Soda (sugar free)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI12000/(FFQ_DRINK _WATER). Water


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI13000/(FFQ_DRINK_KIND_MILK). What kind of milk does your child usually drink?


Label

Code

Go To

Breast milk, breast fed

1

FFQ_DRINK_KIND_WATER

Breast milk, expressed

2

FFQ_DRINK_KIND_WATER

Formula made from cow’s milk

3

FFQ_DRINK_KIND_WATER

Formula made from soy milk

4

FFQ_DRINK_KIND_WATER

Whole milk

5

FFQ_DRINK_KIND_WATER

2% milk

6

FFQ_DRINK_KIND_WATER

1% milk

7

FFQ_DRINK_KIND_WATER

Skim milk

8

FFQ_DRINK_KIND_WATER

Soy milk

9

FFQ_DRINK_KIND_WATER

Not Applicable/My child does not drink milk

-7

FFQ_DRINK_KIND_WATER

Other

-5



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI13100/(FFQ_DRINK_KIND_MILK_OTH). Please specify: __________________________________________


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


DRI14000/(FFQ_DRINK_KIND_WATER). What kind of water does your child usually drink?


Label

Code

Go To

Tap water, not filtered

1

ODA00100

Tap water, filtered

2

ODA00100

Bottled water

3

ODA00100

Other

-5



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


DRI15000/(FFQ_DRINK_KIND_WATER_OTH). Please specify: _____________________________


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



OTHER DAIRY AND EGGS


ODA00100. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA01000/(FFQ_DAIRY_CHEESE). ​Cheese, plain or in sandwiches


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA02000/(FFQ_DAIRY_CRM_CHEESE). ​Cream cheese


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA03000/(FFQ_DAIRY_YOGURT). Yogurt


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA04000/(FFQ_DAIRY_ICE_CREAM). ​Ice cream


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA05000/(FFQ_DAIRY_PUDDING). Pudding


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


ODA06000/(FFQ_DAIRY_EGGS). Whole eggs


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



OILS AND SPREADS


OAS01000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OAS02000/(FFQ_OILS_BUTTER). ​Butter (not margarine)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

​​Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OAS03000/(FFQ_OILS_MARG_TUB). ​Margarine (tub)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

​​Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OAS04000/(FFQ_OILS_MARG_STICK). ​Margarine (stick)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

​​Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OAS05000/(FFQ_OILS _MAYO). Mayonnaise


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

​​Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OAS06000/(FFQ_OILS _DRESSING). Salad dressing


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



SWEETS AND SNACKS


SAS01000. Please check the box that best represents how often your child ate each of the foods listed, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS02000/(FFQ_SNACKS_CHIPS). ​Chips (potato, corn or others)


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS03000/(FFQ_SNACKS_NUTS). Nuts


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS04000/(FFQ_SNACKS_CRACKERS). Crackers


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS05000/(FFQ_SNACKS_JELLO). ​Jello


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS06000/(FFQ_SNACKS_COOKIES). ​Cookies or brownies


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS07000/(FFQ_SNACKS_CAKES). Cake or cupcakes


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS08000/(FFQ_SNACKS_PIE). Pie


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS09000/(FFQ_SNACKS_CHOC_CANDY). Chocolate candy


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


SAS10000/(FFQ_SNACKS_OTH_CANDY). ​Other candy


Label

Code

Go To

Never

1


Less than 1 time per week

2


1 time per week

3


2-4 times per week

4


Nearly every day or every day

5


2 or more times per day

6



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)



OTHER FOODS YOUR CHILD EATS ONCE PER WEEK


OFY00100. Are there any other foods not mentioned above that your child eats at least once per week?  Please write in the name of the food and check the box that best represents how often your child ate each food, on average, in the past month.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OFY01000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS1_NAME) __________________________________


(FFQ_OTHER_FOODS1_FREQ)


OFY02000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS2_NAME) ______________________________


(FFQ_OTHER_FOODS2_FREQ)


OFY03000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS3_NAME) ________________________


(FFQ_OTHER_FOODS3_FREQ)


OFY04000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS4_NAME) ____________________________


(FFQ_OTHER_FOODS4_FREQ)


OFY05000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS5_NAME) ______________________


(FFQ_OTHER_FOODS5_FREQ)


OFY06000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS6_NAME) _______________________


(FFQ_OTHER_FOODS6_FREQ)


OFY07000.


SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


(FFQ_OTHER_FOODS7_NAME) ​________________________


(FFQ_OTHER_FOODS7_FREQ)


OFY08000/(FFQ_FAST_FOOD). In the past month, how often did your child eat fast foods away from home or as take-out, such as hamburgers, french fries, egg rolls, chicken nuggets, fried chicken, etc.?


Label

Code

Go To

Less than once per week

1


1 time per week

2


2 to 4 times per week

3


Nearly every day or every day

4



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)​ (modified)


OFY09000. In the past month, did you always, usually, sometimes, or seldom:


SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_WASH_HANDS) ​Wash your hands before preparing food for your family?


Label

Code

Go To

Always

1


Usually

2


Sometimes

3


Seldom

4



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_WASH_COUNTER) Wash the cutting board or counter before preparing food on it for your family?


Label

Code

Go To

Always

1


Usually

2


Sometimes

3


Seldom

4



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_WASH_FRUITS) Wash or rinse fresh fruits and vegetables 20 seconds and drain 2 minutes before preparing them for your family?


Label

Code

Go To

Always

1


Usually

2


Sometimes

3


Seldom

4



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


OFY10000. In the past month, did your child eat any of the following foods that contain raw eggs:


SOURCE

​​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_COOKIE) ​Raw, homemade cookie or cake batter?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_EGG_FROSTING) ​Homemade frosting with raw egg?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_EGG_SALAD) ​Caesar salad with raw egg?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_EGG_MOUSSE) Chocolate mousse with raw egg?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_EGGNOG) ​Homemade eggnog?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_RAW_EGG_SHAKES) ​Shakes with raw egg?


Label

Code

Go To

Yes

1


No

2


Don’t know

3



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


OFY11000. Where does your child eat, including breakfast, lunch, dinner, and snacks?  For each of these places, mark if he/she eats in these places usually, sometimes, or never.


SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_KITCHEN_TABLE) ​Kitchen table or counter


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_HIGH_CHAIR) ​High chair


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_DINING_TABLE) Dining room table


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_FLOOR) ​On the carpet or floor anywhere in the house


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_BEDROOM) Bedroom on a table or dresser


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_GARAGE) ​Garage


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_OUTSIDE) ​On a table or bench outside the house


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


(FFQ_EAT_ANYWHERE) Anywhere else he or she chooses


Label

Code

Go To

Usually

1


Sometimes

2


Never

3



SOURCE

​​National Children’s Study, Legacy Phase (18-Month FFQ)


OFY12000/(FFQ_SUPPLEMENTS). Which of the following supplements was your child given at least 3 days a week during the past month?


PARTICIPANT INSTRUCTIONS

  • Select all that apply.


Label

Code

Go To

Fluoride

1


Iron

2


Multi-vitamins

3


Other vitamins or supplements

-5


None

4



SOURCE

Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


PROGRAMMER INSTRUCTIONS

  • IF FFQ_SUPPLEMENTS = -5 OR ANY COMBINATION OF 1-3 AND -5, GO TO FFQ_SUPPLEMENTS_OTH.

  • IF FFQ_SUPPLEMENTS = 4, DO NOT ALLOW SELECTION OF OTHER VALUES AND GO TO FFQ_SUPP_DROPS_PILLS.

  • IF FFQ_SUPPLEMENTS = ANY COMBINATION OF 1-3, GO TO FFQ_SUPP_DROPS_PILLS.


OFY13000/(FFQ_SUPPLEMENTS_OTH). ​Please specify: _______________________________


SOURCE

​​Project Viva Second-Year Questionnaire (modified from Harvard-Willett FFQ)


OFY14000/(FFQ_SUPP_DROPS_PILLS). Were any of the supplements you gave your child in the form of drops or pills?


Label

Code

Go To

Drops

1


Pills

2


Both

3



SOURCE

National Children’s Study, Legacy Phase (18-Month FFQ)


OFY15000. ​Thank you for participating in the National Children’s Study and for taking the time to complete this survey.



FOR OFFICE USE ONLY


FOU01000/(P_ID). ​Participant ID:______________________________________________


FOU02000/(R_P_ID). Respondent ID:____________________________________


Public reporting burden for this collection of information is estimated to average 10 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 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.

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