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9-Month Interview
Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months
OMB: 0925-0593
IC ID: 193576
OMB.report
HHS/NIH
OMB 0925-0593
ICR 201407-0925-005
IC 193576
( )
Documents and Forms
Document Name
Document Type
Form 13.1
9-Month Interview
Form and Instruction
13.1 Survey
9MonthQuestionnaireChild.docx
Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx
HIPAAHealthUseDisclosureAuthorizationForm
IC Document
Attach 10. Informed Consent Form - Adult.docx
InformedConsentFormAdult
IC Document
Attach 12. Parental Permission Child Participation - Birth to 6Months.docx
ParentalPermissionChildParticipation6MonthtoAgeMajority
IC Document
Attach 13. Multi-Mode Visit Information Script.docx
MultiModeVisitInformationScript
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
9-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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
13.1
Survey
9MonthQuestionnaireChild.docx
Yes
Yes
Paper Only
Federal Enterprise Architecture Business Reference Module
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:
554
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
554
0
0
0
0
554
Annual IC Time Burden (Hours)
127
0
0
0
0
127
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm
HIPAAHealthUseDisclosureAuthorizationForm.docx
01/14/2014
InformedConsentFormAdult
Attach 10. Informed Consent Form - Adult.docx
07/24/2014
ParentalPermissionChildParticipation6MonthtoAgeMajority
Attach 12. Parental Permission Child Participation - Birth to 6Months.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.