Information Collection

12-Month Interview

IC 193577 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⚠️ Notice: This information collection may be referencing outdated material.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:

2014-07-25 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 14.1 Survey 12-Month Interview	Form and Instruction
Form 14.2 Survey 12-Month Interview	Form and Instruction
Form 14.3 Survey 12-Month Interview	Form and Instruction
Form 14.4 Survey 12-Month Interview	Form and Instruction
Form 14.5 Survey 12-Month Interview	Form and Instruction
Form 14.6 Survey 12-Month Interview	Form and Instruction
Form 14.7 Survey 12-Month Interview	Form and Instruction
Form 14.8 Survey 12-Month Interview	Form and Instruction
Form 14.9 Survey 12-Month Interview	Form and Instruction
14.1 Survey 12MonthASQ3.docx	Form and Instruction
14.2 Survey 12M_14MonthASQ3.docx	Form and Instruction
14.3 Survey 12M_16MonthASQ3.docx	Form and Instruction
14.4 Survey BriefInfantToddlerSocialEmotionalAssessmentSAQ.docx	Form and Instruction
14.5 Survey 12MonthQuestionnaireChild.docx	Form and Instruction
14.6 Survey 12MonthQuestionnaireAdult.docx	Form and Instruction
14.7 Survey 12MonthSAQChild.docx	Form and Instruction
14.8 Survey 12MonthSAQAdult.docx	Form and Instruction
14.9 Survey 12MonthQuestionnaireHousehold.docx	Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
InformedConsentFormAdult.docx InformedConsentFormAdult	IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript	IC Document
ParentalPermissionChildParticipation6MonthtoAgeMajority.docx ParentalPermissionChildParticipation6MonthtoAgeMajority	IC Document
ReconsiderationQuestionnaireAdult.docx ReconsiderationQuestionnaireAdult	IC Document
ReconsiderationQuestionnaireChild.docx ReconsiderationQuestionnaireChild	IC Document
SampleCollectionVIS.docx SampleCollectionVIS	IC Document
ASQ3InPersonMailInstructions.docx ASQ3InPersonMailInstructions	IC Document
BITSEAInPersonMailInstructions.docx BITSEAInPersonMailInstructions	IC Document
BITSEAPhoneInstructions.docx BITSEAPhoneInstructions	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

12-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.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	14.1	Survey	12MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	14.2	Survey	12M_14MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	14.3	Survey	12M_16MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	14.4	Survey	BriefInfantToddlerSocialEmotionalAssessmentSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	14.5	Survey	12MonthQuestionnaireChild.docx	Yes	Yes	Paper Only
Form and Instruction	14.6	Survey	12MonthQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	14.7	Survey	12MonthSAQChild.docx	Yes	Yes	Paper Only
Form and Instruction	14.8	Survey	12MonthSAQAdult.docx	Yes	Yes	Paper Only
Form and Instruction	14.9	Survey	12MonthQuestionnaireHousehold.docx	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

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: 554

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	554	-449	1,003
Annual IC Time Burden (Hours)	478	-358	836
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/14/2014
InformedConsentFormAdult	InformedConsentFormAdult.docx	01/14/2014
MultiModeVisitInformationScript	MultiModeVisitInformationScript.docx	01/14/2014
ParentalPermissionChildParticipation6MonthtoAgeMajority	ParentalPermissionChildParticipation6MonthtoAgeMajority.docx	01/14/2014
ReconsiderationQuestionnaireAdult	ReconsiderationQuestionnaireAdult.docx	01/14/2014
ReconsiderationQuestionnaireChild	ReconsiderationQuestionnaireChild.docx	01/14/2014
SampleCollectionVIS	SampleCollectionVIS.docx	01/14/2014
ASQ3InPersonMailInstructions	ASQ3InPersonMailInstructions.docx	01/15/2014
BITSEAInPersonMailInstructions	BITSEAInPersonMailInstructions.docx	01/15/2014
BITSEAPhoneInstructions	BITSEAPhoneInstructions.docx	01/15/2014

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