24-Month Interview

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

Documents and Forms

Document Name Document Type
Form 16.1 24-Month Interview Form and Instruction
16.1 Survey 24MonthASQ3.docx Form and Instruction
16.2 Survey 24M_27MonthASQ3.docx Form and Instruction
16.4 Survey MCHATSAQ.docx Form and Instruction
16.5 Survey 24MQuestionnaireChild.docx Form and Instruction
16.6 Survey 24MQuestionnaireAdult.docx Form and Instruction
16.7 Survey 24MQuestionnaireHousehold.docx Form and Instruction
16.3 Survey 24M_30MonthASQ3.docx Form and Instruction
ASQ3InPersonMailInstructions.docx ASQ3InPersonMailInstructions IC Document
MCHATInPersonMailInstructions.docx MCHATInPersonMailInstructions IC Document
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm IC Document
Attach 10. Informed Consent Form - Adult.docx InformedConsentFormAdult IC Document
Attach 12. Parental Permission Child Participation - Birth to 6Months.docx ParentalPermissionChildParticipation6MonthtoAgeMajority 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 19. Reconsideration Questionnaire Adult.docx ReconsiderationQuestionnaireAdult IC Document
Attach 20. Reconsideration Questionnaire Child.docx ReconsiderationQuestionnaireChild IC Document

Information Collection (IC) Details

IC Title:	24-Month Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	16.1	Survey	24MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	16.2	Survey	24M_27MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	16.4	Survey	MCHATSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	16.5	Survey	24MQuestionnaireChild.docx	Yes	Yes	Paper Only
Form and Instruction	16.6	Survey	24MQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	16.7	Survey	24MQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	16.3	Survey	24M_30MonthASQ3.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: 1,046	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,046	1,046
Annual IC Time Burden (Hours)	762	762
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ASQ3InPersonMailInstructions	ASQ3InPersonMailInstructions.docx	11/07/2013
MCHATInPersonMailInstructions	MCHATInPersonMailInstructions.docx	11/07/2013
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/15/2014
InformedConsentFormAdult	Attach 10. Informed Consent Form - Adult.docx	07/24/2014
ParentalPermissionChildParticipation6MonthtoAgeMajority	Attach 12. Parental Permission Child Participation - Birth to 6Months.docx	07/24/2014
MultiModeVisitInformationScript	Attach 13. Multi-Mode Visit Information Script.docx	07/24/2014
SampleCollectionVIS	Attach 14. Sample Collection Visit Information Sheet Scripts.docx	07/24/2014
ReconsiderationQuestionnaireAdult	Attach 19. Reconsideration Questionnaire Adult.docx	07/24/2014
ReconsiderationQuestionnaireChild	Attach 20. Reconsideration Questionnaire Child.docx	07/24/2014

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