54-Month Interview

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 36.1 54-Month Interview Form and Instruction
36.1 Survey 54MQuestionnaireChild.docx Form and Instruction
36.2 Survey 54MQuestionnaireAdult.docx Form and Instruction
36.3 Survey DietaryFoodFrequencySAQ.docx Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm IC Document
InformedConsentFormAdult.docx InformedConsentFormAdult IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript IC Document
ParentalPermissionChildParticipation6MonthtoAgeMajority.docx ParentalPermissionChildParticipation6MonthtoAgeMajority IC Document

Information Collection (IC) Details

IC Title:	54-Month Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	36.1	Survey	54MQuestionnaireChild.docx	Yes	Yes	Paper Only
Form and Instruction	36.2	Survey	54MQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	36.3	Survey	DietaryFoodFrequencySAQ.docx	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: 1,431	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,431	1,431
Annual IC Time Burden (Hours)	804	804
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/15/2014
InformedConsentFormAdult	InformedConsentFormAdult.docx	01/15/2014
MultiModeVisitInformationScript	MultiModeVisitInformationScript.docx	01/15/2014
ParentalPermissionChildParticipation6MonthtoAgeMajority	ParentalPermissionChildParticipation6MonthtoAgeMajority.docx	01/15/2014

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