1 Survey

Appendix A A.2.3.l.4–5

National Children’s Study

T3 Mother Blood Draw Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__|		Section Status (Select one) Complete 1 Partial Complete 2 Not Done 3 Reason for Not Done/Partial (Select one) Safety Exclusion 1 Physical Limitations 2 Participant III/Emergency 3 Equipment Failure 4 Communication Problem 5 No Time 6 Other Specify___________________ 96 Refused 97
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___| Site ID: |___|___|___|___| Participant’s age |__|__| years
Part B: Blood Collection Questions
1) Do you have hemophilia or any bleeding disorder? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
2) Do you take any blood-thinning medication, such as Coumadin or Warfarin? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
3) Have you had cancer chemotherapy within the past 4 weeks? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
4) Have you had any problems with a blood draw in the past? 1 Yes 2 No (Go to Q 6) 97 Refuse (Go to Q 6) 98 Don’t Know ( Go to Q 6)
5). What problems did you have with a blood draw in the past? (Check all that apply) Fainting 4 Light-Headedness 5 Hematoma 6				Bruising 7 Other, Specify_________ 96 Refuse 97 Don’t Know 98
6) When was the last time you had anything to eat or drink? |__|__|:|__|__| . 1 am 2 pm
7) Is this a fasting blood sample? (If the answer to Question 6 is less than 8 hours ago the answer is No.) 1 Yes 2 No
8) Have you had coffee or tea today? 1 Yes 2 No 97 Refuse 98 Don’t Know
9) Have you had alcohol such as beer wine or liquor today? 1 Yes 2 No 97 Refuse 98 Don’t Know
10) Have you chewed gum, used breath mints, lozenges or cough drops, or other cough or cold remedies today? 1 Yes 2 No 97 Refuse 98 Don’t Know
11) Have you used antacid, laxatives, or anti-diarrheals today? 1 Yes 2 No 97 Refuse 98 Don’t Know
12) Have you taken a dietary supplement such as vitamins or minerals today? 1 Yes 2 No 97 Refuse 98 Don’t Know
Part C Saliva Collection (Only use if blood collection is refused or not possible)
13) Because you {have hemophilia; are taking blood thinning medication; have had chemotherapy recently} we will not be able to draw your blood at this time. Several measures that are performed in blood can be measured in saliva. Are you able to provide a saliva sample? 1 Yes 2 No BE SURE TO REVIEW SALIVA SAMPLE COLLECTION INSTRUCTIONS WITH THE PARTICIPANT
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
Data Collector ID: |___|___|___|___|
Saliva Status 1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3			Other, Specify_________ 96 Refuse 97 Could Not Obtain 99
Saliva Comments: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
Part D Tubes to be drawn
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
Data Collector ID: |___|___|___|___|
Red top (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5			Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Red top (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Red top (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
PBMC (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Lavender EDTA (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Lavender EDTA (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Gray top NaF (4 ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
PAX GENE RNA (10ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5				Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Blood Collection Comment:________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

5 Revised 9/8/08