Profit/Nonprofit Business

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

Appendix CC.1

Provider Data Request Form - ENGLISH

<TODAY’S DATE>

<NAME>

<NAME OF HOSPITAL>

<RECORDS DEPT>

<ADDRESS>

Dear Provider Records Administrator,

Westat is a contract research organization headquartered in Rockville, Maryland that is under contract to the United States Department of Agriculture, Food and Nutrition Service to conduct a national Women Infant and Children (WIC) Feeding My Baby Study to understand birth, health, growth, and early feeding practices of infants and toddlers between birth and 24 months of age. To this end, we are obtaining health record information for these children during this critical development period.

Enclosed you will find a Medical Records Release Form giving us permission to receive medical records from you for:

Infant/Toddler Name: <INFNM> Date of Birth: <I_DOB>

Please call or e-mail, <_____________________> at xxx-xxx-xxxx, email@westat.com should you have any questions or require assistance. If at all possible we request that we receive the records within 4 weeks of receipt. Records can be transmitted electronically, faxed, or via standard postal service to:

Medical Data Management Group
WESTAT
1500 Research Boulevard, TB132
Rockville, MD  20850
FAX: 240-314-5895

Thank you very much for your assistance with this important research study.

Sincerely,

Gail Harrison, PhD

Feeding My Baby, Principal Investigator

Suzanne McNutt

Feeding My Baby Project Director

Tameka Owens

USDA, Food and Nutrition Service

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number.  The valid OMB control number for this information collection is 0584-XXXX.  The time required to complete this information collection is estimated to average 5 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.