23.3 Survey - Placeholder for copyrighted material

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

16 Month Ages & Stages-3 SAQ, Phase 2e

16 Month Ages & Stages-3 SAQ

(COVER PAGE)

Event:	16 Month
Participant: Respondent:	Child Parent/Caregiver
Domain:	Neuropsychosocial
Type of Document: Allowable Mode: Allowable Method:	Self-Administered Questionnaire Phone, Mail PAPI
Recruitment Groups:	EH, PB, HI, LI, PBS
Version:	1.0
Release: Publisher: NCS Contact:	MDES 3.0 Paul H. Brooks Publishing Co. Carol Andreassen Westat 301-251-1500

The Ages& Stages Questionnaires®, Third Edition (ASQ-3™) is a series of 21 age-specific questionnaires and scoring sheets designed to screen a child’s skills in five developmental areas: fine motor, gross motor, problem solving, communication, and personal-social.  The instrument covers ages 1 month to 66 months.

The ASQ-3 is available in English and Spanish and is a proprietary questionnaire.

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 (0925-0593*). Do not return the completed form to this address.