Information Collection

36-Month Interview

IC 210030 under ICR 201407-0925-005 · OMB 0925-0593.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 38.2 36-Month Interview	Form and Instruction
38.2 Survey 36M_42MonthASQ3.docx	Form and Instruction
38.3 Survey SWANRatingScaleADHDSAQ.docx	Form and Instruction
38.4 Survey EarlyChildHoodCognitionBattery_NIHToolbox.docx	Form and Instruction
38.5 Survey 36M_AlcoholTobaccoSubstanceAbuseCASI.docx	Form and Instruction
38.6 Survey 36M_WomanAbuseScreeningToolCASI.docx	Form and Instruction
38.7 Survey MajorLifeEventsSAQ.docx	Form and Instruction
38.9 Survey 36MQuestionnaireAdult.docx	Form and Instruction
38.10 Survey 36MQuestionnaireHousehold.docx	Form and Instruction
38.11 Survey 36MQuestionnaireChildCare.docx	Form and Instruction
38.1 Survey 36MonthASQ3.docx	Form and Instruction
38.12 Revised Survey 36MQuestionnaireChild_REVISED.docx	Form and Instruction
ASQ3InPersonMailInstructions.docx ASQ3InPersonMailInstructions	IC Document
SWANBehaviorRatingScalesInstructions.docx SWANBehaviorRatingScalesInstructions	IC Document
MajorLifeEventsInstructions.docx MajorLifeEventsInstructions	IC Document
36M_HomeSocialDirectObservationInstrument.docx 36M_HomeSocialDirectObservationInstrument	IC Document
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm	IC Document
InformedConsentFormAdult.docx InformedConsentFormAdult	IC Document
MultiModeVisitInformationScript.docx MultiModeVisitInformationScript	IC Document
ParentalPermissionChildParticipation6MonthtoAgeMajority.docx ParentalPermissionChildParticipation6MonthtoAgeMajority	IC Document
ReconsiderationQuestionnaireAdult.docx ReconsiderationQuestionnaireAdult	IC Document
ReconsiderationQuestionnaireChild.docx ReconsiderationQuestionnaireChild	IC Document
SampleCollectionVIS.docx SampleCollectionVIS	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

36-Month Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	38.2	Survey	36M_42MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	38.3	Survey	SWANRatingScaleADHDSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	38.4	Survey	EarlyChildHoodCognitionBattery_NIHToolbox.docx	Yes	Yes	Paper Only
Form and Instruction	38.5	Survey	36M_AlcoholTobaccoSubstanceAbuseCASI.docx	Yes	Yes	Paper Only
Form and Instruction	38.6	Survey	36M_WomanAbuseScreeningToolCASI.docx	Yes	Yes	Paper Only
Form and Instruction	38.7	Survey	MajorLifeEventsSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	38.9	Survey	36MQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	38.10	Survey	36MQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	38.11	Survey	36MQuestionnaireChildCare.docx	Yes	Yes	Paper Only
Form and Instruction	38.1	Survey	36MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	38.12 Revised	Survey	36MQuestionnaireChild_REVISED.docx	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

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: 1,711

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	1,711	1,711
Annual IC Time Burden (Hours)	2,873	2,873
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ASQ3InPersonMailInstructions	ASQ3InPersonMailInstructions.docx	11/07/2013
SWANBehaviorRatingScalesInstructions	SWANBehaviorRatingScalesInstructions.docx	11/07/2013
MajorLifeEventsInstructions	MajorLifeEventsInstructions.docx	11/07/2013
36M_HomeSocialDirectObservationInstrument	36M_HomeSocialDirectObservationInstrument.docx	11/08/2013
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/15/2014
InformedConsentFormAdult	InformedConsentFormAdult.docx	01/15/2014
MultiModeVisitInformationScript	MultiModeVisitInformationScript.docx	01/15/2014
ParentalPermissionChildParticipation6MonthtoAgeMajority	ParentalPermissionChildParticipation6MonthtoAgeMajority.docx	01/15/2014
ReconsiderationQuestionnaireAdult	ReconsiderationQuestionnaireAdult.docx	01/15/2014
ReconsiderationQuestionnaireChild	ReconsiderationQuestionnaireChild.docx	01/15/2014
SampleCollectionVIS	SampleCollectionVIS.docx	01/15/2014

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