3-Month Interview

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months

Documents and Forms

Document Name Document Type
Form 11.1 3-Month Interview Form and Instruction
11.1 Survey 3M_2MonthASQ3.docx Form and Instruction
11.2 Survey 3M_4MonthASQ3.docx Form and Instruction
11.3 Survey 3M_EdinburghPostNatalDepressScalesSAQ.docx Form and Instruction
11.4 Survey 3M_InfantBehaviorRevised3SubscalesSAQ.docx Form and Instruction
11.5 Survey 3MonthQuestionnaireChild.docx Form and Instruction
11.6 Survey 3MonthQuestionnaireBIOMom.docx Form and Instruction
11.7 Survey 3MonthQuestionnaireAdult.docx Form and Instruction
11.8 Survey 3MonthQuestionnaireHousehold.docx Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm IC Document
ASQ3PhoneInstructions.docx ASQ3PhoneInstructions IC Document
3M_EdinburghPostnatalDepressionScaleInstructions.docx 3M_EdinburghPostnatalDepressionScaleInstructions IC Document
3M_InfantBehaviorRevised3SubscalesInstructions.docx 3M_InfantBehaviorRevised3SubscalesInstructions IC Document
Attach 10. Informed Consent Form - Adult.docx InformedConsentFormAdult IC Document
Attach 13. Multi-Mode Visit Information Script.docx MultiModeVisitInformationScript IC Document

Information Collection (IC) Details

IC Title:	3-Month Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	11.1	Survey	3M_2MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	11.2	Survey	3M_4MonthASQ3.docx	Yes	Yes	Paper Only
Form and Instruction	11.3	Survey	3M_EdinburghPostNatalDepressScalesSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	11.4	Survey	3M_InfantBehaviorRevised3SubscalesSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	11.5	Survey	3MonthQuestionnaireChild.docx	Yes	Yes	Paper Only
Form and Instruction	11.6	Survey	3MonthQuestionnaireBIOMom.docx	Yes	Yes	Paper Only
Form and Instruction	11.7	Survey	3MonthQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	11.8	Survey	3MonthQuestionnaireHousehold.docx	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 475	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	475	475
Annual IC Time Burden (Hours)	372	372
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/14/2014
ASQ3PhoneInstructions	ASQ3PhoneInstructions.docx	01/15/2014
3M_EdinburghPostnatalDepressionScaleInstructions	3M_EdinburghPostnatalDepressionScaleInstructions.docx	01/15/2014
3M_InfantBehaviorRevised3SubscalesInstructions	3M_InfantBehaviorRevised3SubscalesInstructions.docx	01/15/2014
InformedConsentFormAdult	Attach 10. Informed Consent Form - Adult.docx	07/24/2014
MultiModeVisitInformationScript	Attach 13. Multi-Mode Visit Information Script.docx	07/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.