Questionaire Packets

Appendix H.1

Form Approved

OMB NO. __________

Exp. Date __________

Form Approved

OMB NO. __________

Exp. Date __________

Three Day Diet Diary

Thank you for your time and effort in this study. The following is a diary to keep track of what your child consumes during the week of the stool collection. Please be as detailed as possible in the spaces provided for the most accurate analysis of your child’s diet. Be sure to include any vitamins, herbs or other supplements. If your child spikes a temperature or seems to get the stomach flu please discontinue the food diary. Please document if this week’s intake was typical on the last day of recording.

Complete your diet record including details as in the example below:

Time eaten

Amount EATEN

What did you eat?

Brand name

Type (low fat, low sugar, creamy, crispy…)

Preparation / Cooking method

6 pm

½8 oz

Water

Evian

Drinking Water

“

8 oz

Diet Soda

Coke

Caffeine free

3 oz

Steak

Rib Eye

Trimmed fat, grilled

“

2

Celery sticks

2 pills

Multiple Vitamin

Flintstones

children’s chewable

If you have any questions, please call <Principal Investigator>

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 20 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-XXXX)

Day of week: M Tu W Th F Sa Su

Please circle the day of the week

Date:

Time eaten	Amount EATEN	What did you eat?	Brand name	Type (low fat, low sugar, creamy, crispy…)	Preparation / Cooking method