42-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 34.1 42-Month Interview Form and Instruction
34.1 Survey EmotionBattery_NIHToolbox.docx Form and Instruction
34.3 Survey DietaryFoodFrequencySAQ.docx Form and Instruction
34.5 Survey 42M_FamilyMedicalHistorySAQ.docx Form and Instruction
34.6 Survey 42MFamilyMedicalHistorySupplemental.docx Form and Instruction
34.7 Survey ParticipantSatisfactionSAQ.docx Form and Instruction
34.4 Survey 42M_ChronicMedicalHistorySAQ.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

IC Title:	42-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	34.1	Survey	EmotionBattery_NIHToolbox.docx	Yes	Yes	Paper Only
Form and Instruction	34.3	Survey	DietaryFoodFrequencySAQ.docx	Yes	Yes	Paper Only
Form and Instruction	34.5	Survey	42M_FamilyMedicalHistorySAQ.docx	Yes	Yes	Paper Only
Form and Instruction	34.6	Survey	42MFamilyMedicalHistorySupplemental.docx	Yes	Yes	Paper Only
Form and Instruction	34.7	Survey	ParticipantSatisfactionSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	34.4	Survey	42M_ChronicMedicalHistorySAQ.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: 1,364	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	1,364	1,364
Annual IC Time Burden (Hours)	1,313	1,313
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/15/2014
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.