Self Administered Forms

Attachment 8.j.

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 includes 4 forms for you to fill out.

If you feel that you can complete the materials 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 also 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 have any questions please call me 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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