ASD - POST ENROLLMENT _F/U Phone Call / Pregnancy Ref Form- (Mother)

Attachment 7. b. Form Approved

OMB No. 0920-XXXX

Exp. Date:  XX/XX/2020

Study to Explore Early Development

PREGNANCY REFERENCE FORM

This form was completed using the interview you provided to us during your brief interview about the timing of your pregnancy and breast-feeding.

2^ND TRIMESTER

1^ST TRIMESTER

PRE-PREGNANCY

MOTHER’S NAME____________________________ CHILD’S NAME:

			START DATE				END DATE
LINE			Month	Day	Year	to	Month	Day	Year
-3		3 Months PRE-pregnancy (-3)				to
-2		2 Months PRE-pregnancy (-2)				to
-1		1 Month PRE-pregnancy (-1)				to
		Total time period before pregnancy				to
1		MONTH 1 of pregnancy				to
2		MONTH 2 of pregnancy				to
3		MONTH 3 of pregnancy				to
		Total 1st Trimester				to
4		MONTH 4 of pregnancy				to
5		MONTH 5 of pregnancy				to
6		MONTH 6 of pregnancy				to
		Total 2nd Trimester				to
7		MONTH 7 of pregnancy				to
8		MONTH 8 of pregnancy				to
9		MONTH 9 of pregnancy				to
10		MONTH 10 of pregnancy				to
		Total 3rd Trimester				to
DOB		Date of BIRTH
BF		# of days/ weeks/months breastfed

BREASTFEEDING

3^RD TRIMESTER

Version 9-16

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).