SEED - Biosamples (cheek swab and blood)

The Study to Explore Early Development (SEED)

Appendix_R.2 Study Start Blood Draw form child 2007

SEED - Biosamples (cheek swab and blood)

OMB: 0920-0741

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S tudy to Explore Early Development



Interviewer_______________ Study ID#_____________

Date of Completion ___________

Time of Completion___________


Blood Draw Information Form


1. List all medications, vitamins, and supplements, both prescription and over the counter, <child> 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) _______________________ □ □ □




3. Has <child> been exposed to tobacco smoke in the last 4 hours? __Yes __No





4a.What food or foods did <child> 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 <child>.

Describe:














Version 9-07 SNC Page 2 of 2

File Typeapplication/msword
File TitleStudy Start Blood Draw form 2007
AuthorBusiness Center One
Last Modified Byzhv7
File Modified2009-08-28
File Created2009-08-28

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