Information Collection

54-Month Interview

IC 210028 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.