Birth 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 8.1 Birth Interview Form and Instruction
8.1 Survey BirthQuestionnaireAdult.docx Form and Instruction
8.2 Survey BirthQuestionnaireHousehold.docx Form and Instruction
8.3 Survey BirthQuestionnaireChild.docx Form and Instruction
HIPAAHealthUseDisclosureAuthorizationForm.docx HIPAAHealthUseDisclosureAuthorizationForm IC Document
Attach 11. Parental Permission Child Participation-6MtoAgeofMajority.docx ParentalPermissionChildParticipationBirthto6Months IC Document
Attach 13. Multi-Mode Visit Information Script.docx MultiModeVisitInformationScript IC Document
Attach 14. Sample Collection Visit Information Sheet Scripts.docx SampleCollectionVIS IC Document
Attach 15. HIPAA Authorization to Obtain Bodily Fluids and Tissues.docx HIPAAUseBiologicalSamplesAuthorizationForm IC Document
Attach 16. Authorization for Release of Birth Certificate.docx BirthCertificateAuthorizationForm IC Document

Information Collection (IC) Details

IC Title:	Birth 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	8.1	Survey	BirthQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	8.2	Survey	BirthQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	8.3	Survey	BirthQuestionnaireChild.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: 317	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	317	317
Annual IC Time Burden (Hours)	214	214
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HIPAAHealthUseDisclosureAuthorizationForm	HIPAAHealthUseDisclosureAuthorizationForm.docx	01/14/2014
ParentalPermissionChildParticipationBirthto6Months	Attach 11. Parental Permission Child Participation-6MtoAgeofMajority.docx	07/24/2014
MultiModeVisitInformationScript	Attach 13. Multi-Mode Visit Information Script.docx	07/24/2014
SampleCollectionVIS	Attach 14. Sample Collection Visit Information Sheet Scripts.docx	07/24/2014
HIPAAUseBiologicalSamplesAuthorizationForm	Attach 15. HIPAA Authorization to Obtain Bodily Fluids and Tissues.docx	07/24/2014
BirthCertificateAuthorizationForm	Attach 16. Authorization for Release of Birth Certificate.docx	07/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.