30-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 27.1 30-Month Interview Form and Instruction
27.1 Survey BriefInfantToddlerSocialEmotionalAssessmentSAQ.docx Form and Instruction
27.2 Survey 30M_BriefSymptomInventorySAQ.docx Form and Instruction
27.3 Survey 30M_InfantToddlerSensoryProfileSAQ.docx Form and Instruction
27.4 Survey 30MQuestionnaireChild.docx Form and Instruction
27.5 Survey 30MQuestionnaireAdult.docx Form and Instruction
BITSEAInPersonMailInstructions.docx BITSEAInPersonMailInstructions IC Document
BITSEAPhoneInstructions.docx BITSEAPhoneInstructions IC Document
30M_BSIMailInstructions.docx 30M_BSIMailInstructions IC Document
30M_InfantToddlerSensoryProfileMailInstructions.docx 30M_InfantToddlerSensoryProfileMailInstructions IC Document
30M_InfantToddlerSensoryProfilePhoneInstructions.docx 30M_InfantToddlerSensoryProfilePhoneInstructions IC Document
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:	30-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	27.1	Survey	BriefInfantToddlerSocialEmotionalAssessmentSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	27.2	Survey	30M_BriefSymptomInventorySAQ.docx	Yes	Yes	Paper Only
Form and Instruction	27.3	Survey	30M_InfantToddlerSensoryProfileSAQ.docx	Yes	Yes	Paper Only
Form and Instruction	27.4	Survey	30MQuestionnaireChild.docx	Yes	Yes	Paper Only
Form and Instruction	27.5	Survey	30MQuestionnaireAdult.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: 1,286	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	1,286	1,286
Annual IC Time Burden (Hours)	1,302	1,302
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
BITSEAInPersonMailInstructions	BITSEAInPersonMailInstructions.docx	11/07/2013
BITSEAPhoneInstructions	BITSEAPhoneInstructions.docx	11/07/2013
30M_BSIMailInstructions	30M_BSIMailInstructions.docx	11/07/2013
30M_InfantToddlerSensoryProfileMailInstructions	30M_InfantToddlerSensoryProfileMailInstructions.docx	11/07/2013
30M_InfantToddlerSensoryProfilePhoneInstructions	30M_InfantToddlerSensoryProfilePhoneInstructions.docx	11/07/2013
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.