No number Appendix R.2 Blood Draw Form

Appendix R.2 Blood Draw Information Form
Form Approved
OMB NO. __________
Exp. Date __________

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-XXXX)

Interviewer_______________
Respondent_______________

ID#__________
Date__________
Time __________

Child Blood Draw Information Form
1. List all medications, vitamins, and supplements, both prescription and over the
counter, has taken in the last month. Check box for MOST RECENT time frame
when medication was last taken:
If no medications, vitamins, or supplements given in last month, check here: _______

Name of medication,
vitamin or supplement

Last 4
hours

Last 24
hours

Last 3
days

Last 7
days

Last
month

1) _______________________
2) _______________________
3) _______________________
4) _______________________
5) _______________________
6) _______________________
7) _______________________
8) _______________________
9) _______________________
10) ______________________

2. List any cold, flu or other illness child has had in the last 2 weeks. Check box for
MOST RECENT time frame when illness occurred:
If no illness in last 2 weeks, check here: _______
Illness

Today

Last 2
days

Last 2
weeks

1) _______________________
2) _______________________
3) _______________________
4) _______________________
5) _______________________

Created 05/31/2005
2005 Version 1

ID#_______

3. Has been exposed to tobacco smoke in the last 4 hours? ___Yes ____No

4a.What food or foods did eat during their last meal or snack? List:

4b.What time was that food eaten? Time:

5. Has there been a significant event in the child’s life during the past month? Examples
of a significant event may include: illness or death in the family, divorce, moving or
relocation, new school or day care, or other potentially stressful situation for .
Describe:

Created 05/31/2005
2005 Version 1