Att 21d_Follow-up Call Checklist

Attachment 21.d Form Approved

OMB No. 0920-XXXX

Exp. Date:  XX/XX/XXXX

Study to Explore Early Development

SEED Follow-up Call

Checklist of items to be covered during call

1. Introduce self

2. Explain purpose of call

3. Ask if it is ok to tape call for quality assurance purposes

4. Verify that participant received enrollment packet

5. Ask if participant had a chance to review materials in enrollment packet

6. Inquire if participant had any questions regarding the information provided in the enrollment packet (copy of written consent form to review, Study Bill of Rights, Study Flow Sheet)

7. Complete the Pregnancy Reference Form (5 minutes)

8. Confirm appointment to complete the Maternal Interview

9. Inform participant that the pregnancy calendar, the Maternal Interview Preparatory Guide and a $30 incentive for completing this call will be mailed in advance of the interview. The guide includes reference lists of select medical conditions, medications, and other medical treatments for the biological mother and child.

Public reporting burden of this collection of information is estimated to average 15 minutes, 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0010).