Form No number No number Appendix E.21 Buccal Transmittal Form

Form Approved

OMB NO. 0920-0741

Exp. Date 6/30/2010

Study to Explore Early Development (SEED)

Cheek Swab Sample Record Sheet

Please complete this form while collecting your cheek swab samples. Use one form per person. See the instructions on the sheet titled “How to Collect Cheek Swab Samples” for more information.

Section A

Please answer these questions about the person giving these samples. Give both the date and time.

When did they last eat food?	___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM M M D D Y Y (circle one)
When did they last brush their teeth?	___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM M M D D Y Y (circle one)
When were the samples collected?	___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM M M D D Y Y (circle one)

Section B

Please answer all 3 questions about each of the 3 brushes used to collect the samples.

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 5 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)

Section C

Tell us if you had any problems when collecting the samples. The first one is given as an example.

Brush #	Description of problems and other comments
2	Example:	My child did not let me put the brush in his mouth at first, then he bit the brush.

Section D

See the directions on the sheet titled “How to Collect Cheek Swab Samples” to properly package and mail the samples to us. Please answer this final question.

When are you mailing the samples to us?

___ ___ / ___ ___ / 20 ___ ___ M M D D Y Y

Thank You!

Section E To be completed by CADDRE Lab. Do not write in this box.
Date and Time of Receipt			___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM M M D D Y Y (circle one)
Brush #	Received	Packaging		Consent Rec’d	Notes		Sample Quality
1	 Yes	 Satisfactory		 Yes			 Good  Bad
2	 Yes	 Satisfactory		 Yes			 Good  Bad
3	 Yes	 Satisfactory		 Yes			 Good  Bad
Signature of Technician						Date