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

The Study to Explore Early Development (SEED) - Phase 3 (Modified for COVID-19 Impact Assessment)

Attachment 7.b. Pregnancy Reference Form SEED 3_9_19_16

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

OMB: 0920-1171

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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.





Shape3 Shape2 Shape1

2ND TRIMESTER

1ST 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










Shape4 Shape5

BREASTFEEDING

3RD 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).


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorLaura Schieve
File Modified0000-00-00
File Created2021-02-19

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