Information Collection

Pregnancy Visit 1 Interview

IC 193565 under ICR 201407-0925-005 · OMB 0925-0593.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4.1 Survey Pregnancy Visit 1 Interview	Form and Instruction
Form 4.2 Survey Pregnancy Visit 1 Interview	Form and Instruction
Form 4.4 Survey Pregnancy Visit 1 Interview	Form and Instruction
Form 4.3 Survey Pregnancy Visit 1 Interview	Form and Instruction
4.1 Survey EmotionBattery_NIHToolbox.docx	Form and Instruction
4.2 Survey PV1QuestionnnaireHousehold.docx	Form and Instruction
4.4 Survey PV1SAQ.docx	Form and Instruction
4.3 Survey PV1QuestionnaireAdult.docx	Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
Attach 8. Informed Consent Form - Pregnant Woman.docx InformedConsentFormPregnantWoman	IC Document
Attach 11. Parental Permission Child Participation-6MtoAgeofMajority.docx ParentalPermissionChildParticipationBirthto6Months	IC Document
Attach 13. Multi-Mode Visit Information Script.docx MultiModeVisitInformationScript	IC Document
Attach 14. Sample Collection Visit Information Sheet Scripts.docx SampleCollectionVIS	IC Document
Attach 15. HIPAA Authorization to Obtain Bodily Fluids and Tissues.docx HIPAAUseBiologicalSamplesAuthorizationForm	IC Document
Attach 19. Reconsideration Questionnaire Adult.docx ReconsiderationQuestionnaireAdult	IC Document

IC Title:

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	4.1	Yes	Yes	Paper Only
Form and Instruction	4.2	Yes	Yes	Paper Only
Form and Instruction	4.4	Yes	Yes	Paper Only
Form and Instruction	4.3	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: 333

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	Previously Approved
Annual Number of Responses for this IC	333	333
Annual IC Time Burden (Hours)	481	481
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm		01/14/2014
InformedConsentFormPregnantWoman		07/24/2014
ParentalPermissionChildParticipationBirthto6Months		07/24/2014
MultiModeVisitInformationScript		07/24/2014
SampleCollectionVIS		07/24/2014
HIPAAUseBiologicalSamplesAuthorizationForm		07/24/2014
ReconsiderationQuestionnaireAdult		07/24/2014

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

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