0920-21BF Survey Cover Sheet

Form Approved

OMB NO. 0920-1171

Exp. Date 12/31/2021

Study to Explore Early Development

COVID-19 Impact Study

Assessment Packet

Paperwork Reduction Act Notice: Public reporting burden of this collection of information is estimated to average 70 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 (0920-1171).

Study to Explore Early Development

COVID-19 Impact Study

Assessment Packet

Please complete this survey and return it with the following:

• The Child Behavior Checklist

• The Vineland-3 Parent/Caregiver form

	1.		Are you the legal guardian of the child who participated in the Study to Explore Early Development (SEED), referred to as “the study child”?
				Yes
				No

	2.		Did the study child live in your household during 2020?
				Yes
				No

	3.		Is the study child currently living in your household?
				Yes
				No

	4.		Will you allow SEED to contact you for future studies? If you agree, this would allow an approved team member to contact you by mail or telephone to invite you and your child to be in another study related to developmental disabilities.
				Yes
				No