Form 6 Adults Usage Log

Attachment 16

Data collection instrument: Adults - Program Usage Log

OMB Control Number: 0925-XXXX Expiration Date: 09/13/2014

Public reporting burden for this collection of information is estimated to average 10 minutes per response, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

OMB #: 0925-NEW

Expiration Date: 09/13/2014

innovation Research & Training, Inc.

Address: 1415 W NC Highway 54, Suite 121, Durham, NC 27707

Voice: 919 493-7700 Fax: 919 493-7720

Family Media Project

Program Usage Log

Log for month(s): ________________

Date of program use	How long did you use the program this time? (minutes)	Who used the program? (Remember, the entire family is welcome to use either of the programs together, but the parent and child participating in this research study must always be present when the computer program is used.)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

You will need to bring this log with you to the next data collection appointment.

If you have any questions or concerns, you may contact Dr. Tracy Scull of innovation Research and Training, Inc. by email (tscull@irtinc.us) or by phone (919) 493-7700.

Thank you again for your participation!

OMB #: 0925-NEW

Expiration Date: xx/xxxx

Family Media Project

Program Usage Log—Page 2

Date of program use	How long did you use the program this time? (minutes)	Who used the program? (Remember, the entire family is welcome to use either of the programs together, but the parent and child participating in this research study must always be present when the computer program is used.)
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

You will need to bring this log with you to the next data collection appointment.

If you have any questions or concerns, you may contact Dr. Tracy Scull of innovation Research and Training, Inc. by email (tscull@irtinc.us) or by phone (919) 493-7700.

Thank you again for your participation!