BirthCertificateAuthorizationForm

OMB #: 0925-0593

OMB Expiration Date: 06/30/2017

N

ational Children’s Study

Authorization for Release of

Birth Certificate

Full Name of Child

Sex of child: Male Female

Date of Birth: /  / 

Month Day Year

Place of Birth- Hospital/Clinic (if applicable)

____________________ 

Place of Birth- City Place of Birth- State

The measurement of children’s health is a primary research aim of the National Children’s Study (NCS). Information from the birth certificate, such as birth weight, will help us better understand children’s growth and development throughout childhood. We are asking you to authorize the state office of vital records to release the birth certificate information of the child named above to researchers from the NCS.

Your child’s birth certificate information will be used for research purposes only. All information will be kept private. Names and other identifying information will not be released without your permission.

 I PERMIT the NCS to obtain my child’s birth certificate information.

 I DO NOT PERMIT the NCS to obtain my child’s birth certificate information.

_________________________________________ _________________________________________________

Printed parent/guardian name (first, middle, last) Signature of parent/guardian

_________________________________________________

Relationship to Child

Date signed: // - -

m m d d y y y y Phone number

Questions related to the collection of birth certificate information can be answered by NCS staff at 1-877-865-2619.

Public reporting burden for this collection of information is estimated to average 5 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.

Authorization for Release of Birth Certificate Information, MDES 4.1, V1.0 1