Appendix
A A.2.3.l.6–
National Children’s Study
Part A: Administrative |
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Date: |__|__| / |__|__| / |__|2___0_|__|__|
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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 Don’t Know 98
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Assignment ID: |___|___|___|___|___|___|
Participant ID: |___|___|___|___|___|___|
Data Collector ID: |___|___|___|___|
Site ID: |___|___|___|___|
Participant’s age |__|__| months
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Part B: Blood Collection Questions (Ask these questions at all visits when blood is drawn for the child.) |
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1) Does _____ (child’s name) have hemophilia or any bleeding disorder? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
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2) Does _____ (child’s name) take any blood-thinning medication, such as Coumadin or Warfarin? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
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3) Has _____ (child’s name) had cancer chemotherapy within the past 4 weeks? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
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4) Has _____ (child’s name) 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)
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5). What problems did _____ (child’s name) have with a blood draw in the past? (Check all that apply) Fainting 1 Light-Headedness 2 Hematoma 3 Bruising 4 Other Specify___________________ 96 Refused 97 Don’t Know 97
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6) When was the last time _____ (child’s name) had anything to eat or drink? |__|__|:|__|__| 1 am 2 pm |
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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
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Part C Saliva Collection (Only use if blood collection is refused or not possible) |
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8) Because your child {has hemophilia; is taking blood thinning medication; has had chemotherapy recently} we will not be able to draw his/her blood at this time. Several measures that are performed in blood can be measured in saliva. Is _____ (child’s name) able to provide a saliva sample? 1Yes 2 No BE SURE TO REVIEW SALIVA SAMPLE COLLECTION INSTRUCTIONS WITH THE PARTICIPANT |
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Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___| |
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9) Saliva collection status 1 Collected 2 Not Collected Reason for not collecting No Time 1 Participant III/Emergency 2 Equipment Failure 3 Other Specify___________________ 96 Refused 97 Don’t Know 98 Could Not Obtain 99 |
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Saliva Comments: ________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Part D Tubes to be drawn for Child at 12 Months |
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Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___| |
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Red top (5ml) |
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 Don’t Know 98 |
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Tube barcode |
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Red top (5ml) |
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 Don’t Know 98 |
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Tube barcode |
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Lavender top (6ml) |
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 Don’t Know 98 |
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Tube barcode |
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Pre-screened lavender top (3ml) |
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 Don’t Know 98 |
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Tube barcode |
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Blood Collection Comment:________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ |
File Type | application/msword |
File Title | National Children’s Study |
Author | Gillian Devereux |
Last Modified By | DHHS |
File Modified | 2008-09-19 |
File Created | 2008-09-19 |