Appendix_E

Form Approved

OMB NO. 0920-0741

Exp. Date 6/30/2010

S tudy to Explore Early Development

<date>

Dear Mr./Ms. <name>:

Thank you for taking part in the Study to Explore Early Development. An important part of this study is to collect information from medical records.

Collecting information from medical records will help us learn about medical events and history that may be important to child development. Medical records often have important information that is hard to remember, such as fevers or illnesses, prescribed medications, and exact dates. That is why we would like to look at the medical records of the biological mother from all medical providers seen during the three years before <child’s name> date of birth. We would also like to look at the birth hospital record and pediatric records of your child. It is very important for us to look at the records of all types of families, even if the family does not have a child with a developmental delay. Learning more about the differences in children’s medical records may give us clues about child development.

We need your written consent to collect information from medical records. By signing the enclosed Health Insurance Portability and Accountability Act (HIPAA) forms for each provider, you give us permission to collect information from the medical records. Please be sure to check each type of provider we may contact on the check list in the enclosed packet.

It is important for us to look at records of biological mothers. If you are not your child’s biological mother of your child, we ask that you please provide us with her contact information. You can write this information on the form instead of signing.

Please return the signed HIPAA forms and provider checklist in the envelope provided. You can also give the forms to study staff at your first study visit. If you have any questions about the study or the enclosed forms, please call < study coordinator contact info>.

Thank you again for taking part in this important study.

Sincerely,

<Project Coordinator>

Study to Explore Early Development

Provider Checklist

Please check the box of all the providers that we may contact to access the biological mother’s and child’s medical records. We are asking you to complete this checklist to ensure that we can collect as much medical information as possible on the biological mother and child.

Biological Mother:

□ Primary care physician (example: family doctor or internal medicine)

□ Obstetrician

□ Gynecologist

□ Allergist/immunologist

□ Rheumatologist

□ Psychiatrist

□ Infertility specialist/reproductive endocrinologist

□ Other (Please specify): _____________________________

Child in Study:

□ Pediatrician

□ Developmental pediatrician

□ Allergist/immunologist

□ Psychiatrist

□ Neurologist

□ Other (Please specify): _______________________________

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 15 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0741)