Information Collection

3-Month Interview

IC 193574 under ICR 201401-0925-004 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 11.1 Survey 3-Month Interview	Form and Instruction
Form 11.2 Survey 3-Month Interview	Form and Instruction
Form 11.3 Survey 3-Month Interview	Form and Instruction
Form 11.4 Survey 3-Month Interview	Form and Instruction
Form 11.5 Survey 3-Month Interview	Form and Instruction
Form 11.6 Survey 3-Month Interview	Form and Instruction
Form 11.7 Survey 3-Month Interview	Form and Instruction
Form 11.8 Survey 3-Month Interview	Form and Instruction
11.1 Survey 3M_2MonthASQ3.docx	Form and Instruction
11.2 Survey 3M_4MonthASQ3.docx	Form and Instruction
11.3 Survey 3M_EdinburghPostNatalDepressScalesSAQ.docx	Form and Instruction
11.4 Survey 3M_InfantBehaviorRevised3SubscalesSAQ.docx	Form and Instruction
11.5 Survey 3MonthQuestionnaireChild.docx	Form and Instruction
11.6 Survey 3MonthQuestionnaireBIOMom.docx	Form and Instruction
11.7 Survey 3MonthQuestionnaireAdult.docx	Form and Instruction
11.8 Survey 3MonthQuestionnaireHousehold.docx	Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
InformedConsentFormAdult.docx InformedConsentFormAdult	IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript	IC Document
ASQ3PhoneInstructions.docx ASQ3PhoneInstructions	IC Document
3M_EdinburghPostnatalDepressionScaleInstructions.docx 3M_EdinburghPostnatalDepressionScaleInstructions	IC Document
3M_InfantBehaviorRevised3SubscalesInstructions.docx 3M_InfantBehaviorRevised3SubscalesInstructions	IC Document

IC Title:

3-Month Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	11.1	Yes	Yes	Paper Only
Form and Instruction	11.2	Yes	Yes	Paper Only
Form and Instruction	11.3	Yes	Yes	Paper Only
Form and Instruction	11.4	Yes	Yes	Paper Only
Form and Instruction	11.5	Yes	Yes	Paper Only
Form and Instruction	11.6	Yes	Yes	Paper Only
Form and Instruction	11.7	Yes	Yes	Paper Only
Form and Instruction	11.8	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 475

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	475	-1,043	1,518
Annual IC Time Burden (Hours)	372	-134	506
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm		01/14/2014
InformedConsentFormAdult		01/14/2014
MultiModeVisitInformationScript		01/14/2014
ASQ3PhoneInstructions		01/15/2014
3M_EdinburghPostnatalDepressionScaleInstructions		01/15/2014
3M_InfantBehaviorRevised3SubscalesInstructions		01/15/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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