1 Survey

Appendix A A.2.3.g–2

Date Kit provided to participant: |__|__| / |__|__| / |__|2___0_|__|__| KIT ID	Date Samples picked up |__|__| / |__|__| / |__|2___0_|__|__|
Assignment ID: Participant ID: Data Collector ID:	Site ID: Visit type: P1

National Children’s Study

Pregnancy Test Urine Data Collection Form

As part of the National Children’s Study, we are asking you to collect a urine sample the morning after your positive pregnancy test. This should be an early morning sample, collected the first time you urinate after you awake to start your day. This collection is called a first morning void.

You have been provided with a pre-labeled urine collection cup with lid, 2 paper towels, a sealable plastic bag, and the instructions you will need to collect your urine sample. Please follow the instructions provided.

Questions for Urine Collection	Response
1) What was the date of your positive pregnancy test?	___ ___ /___ ___ / ___ ___ ___ ___
2) What is today’s date?	___ ___ /___ ___ / ___ ___ ___ ___
3) What time did you collect your sample this morning?	___ ___ : ___ ___ am
4) Was this your first morning void (first urination after you awoke)?	□ Yes, □ No, □ Not sure Comment:_______________________
5) What was the time of your last urination prior to this morning’s collection? (check am or pm)	___ ___ : ___ ___ a. __ am b. __ pm
6) What time did you place the sample in the freezer?	___ ___ : ___ ___ am
7) Comments/Notes:	__________________________________________ __

Please place this completed form in the side pouch of the bag with your urine cup.

Thank you for providing this sample!