A.2.3.j2 Survey

Appendix A A.2.3.j–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: □ T1 Mom □ T1 Prior □ T1 Dad Visit type: □ T3 First □ T3 Prior □ 6 Month

National Children’s Study

DAY 1: ADULT SALIVA DATA COLLECTION FORM

**Please collect your saliva sample on the 2 days following our visit to your home on __________. Please write down the exact time that you collected each saliva sample in the spaces below.

Day 1 Saliva Samples

What is the date you collected the Day 1 saliva samples? ____/___ /____

Month Day Year

Tube #	When to take sample	Time collected	For Office Use Only
Wake	As soon as you wake up	_____:_____ a. __ am b. __ pm (Answer questions 1 & 2)	Sample collected Yes No

Please answer the following question after you have collected the Wake saliva sample:

1. Did you spend any time dozing in bed within 2 hours before the time that you woke up and collected the first saliva sample (Wake saliva sample) this morning?

Yes No

2. If yes, estimate of time spent dozing before collecting the Wake saliva sample.

________________ minutes

Tube #	When to take sample	Time collected	For Office Use Only
+30	30 minutes after waking up	_____:_____ a. __ am b. __ pm (check am or pm)	Sample collected Yes No

Tube #	When to take sample	Time collected	For Office Use Only
Bedtime	Before brushing your teeth and at least 1 hour after eating for the last time today	_____:_____ a. __ am b. __ pm (Answer questions 3, 4 & 5)	Sample collected Yes No

Please answer the following questions after you have collected the Bedtime saliva sample:

3. During the past 2 hours have you done any of the following:

a. Consumed a caffeinated beverage (coffee, tea, soda)? Yes No

b. Smoked? Yes No

c. Consumed alcohol? Yes No

4. During the past 2 hours has your physical activity been (circle the correct answer):

Light? (standing, walking light, light house work)

Moderate? (yard work, brisk walking)

Intense? (jogging, exercise classes)

5. Please write down the name of any prescription or over the counter medications that you have taken today. Please be specific. For example, if you took Robitussin DM^®, write Robitussin DM^® not Robitussin^®.

_________________________________ ____________________________

_________________________________ ____________________________

_________________________________ ____________________________

Please feel free to call if you have any questions:

[X at phone #]