Self Administered Forms (Mother)

Attachment 8.i.

Form Approved

OMB No. 0920-XXXX

Exp. Date:  XX/XX/2020

Study to Explore Early Development

Date

Name

Address

Address

Dear Name:

Thank you for your interest in the Study to Explore Early Development (SEED). This packet has information to prepare you for the clinic visit and forms to fill out. The package has two folders that will guide you through the study. Someone from the study will call you to make sure you received the packet, help you complete materials if needed, and answer your questions. The folders contained in this packet are:

Yellow Folder: Things You Should Keep Incentive Clinic Visit Prep Guide Biological Sampling FAQ Picture Story for your child about the clinic visit

Green Folder: Forms to Fill Out and Return 6 <Optional: 7> forms to fill out about family history and child development

Please read over all of the materials in all folders.

If you feel that you can complete the materials in the green folder on your own, go ahead and fill them out. Please follow the instructions given and send the materials back to us. If you have any questions about completing these forms (or want help before you begin), please call <staff> at <number>. They can help you over the phone or set up a meeting with study staff.

There is a $45 <money order/cash card/Visa card> enclosed to thank you for participating in the maternal interview. We thank you for your willingness to participate in this important research study. If you would like to speak to anyone at any point during the study, please call us at the number above. You may also call me directly at <phone number>.

Sincerely,

<site Project Coordinator>

Version 9-2015

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

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