1 Survey

Appendix A A.2.3.h–3

National Children’s Study

Vaginal Swabs Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__| Time collection started: |__|__|:|__|__| 1 am 2 pm Time collection stopped: |__|__|:|__|__| 1 am 2 pm	Section Status (Select one) Complete 1 Partial Complete 2 Not Done 3 Reason for Not Done/Partial (Select one) SP Refusal 1 SP III/ Emergency 3 No Time 4 Physical Limitations 11 Defective Collection Kit 15 Language Issue, Spanish 17 Language Issue, Non-Spanish 18 Cognitive Disability 20 No Time (no appt. set for next data collection) 25 Other Specify___________________ 96 Visit Type P1 T1 Mom T1 Prior T3 First T3 Prior
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___| Site ID: |___|___|___|___| Visit location: 1 Home 2 Clinic/Office Participant’s age |__|__| years
Part B: Vaginal Swab Collection Questions
1) Have you had intercourse within the past 2 days? 1 Yes 2 No 97 Refuse 98 Don’t know
2) What was the first day of your last menstrual period? |__|__| / |__|__| / |__|2___0_|__|__| Month Day Year
Part C: Vaginal Swab Collection
Kit ID: (Affix Pre-printed Vaginal Swab Kit ID Label Here)
VSB-0001		Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Collected (Select one) Physical Limitations 1 Participant III/ Emergency 2 Defective Collection Kit 3 Communication Problem 4 No Time 5 Other Specify___________________ 96 Refused 97
VSB-0002		Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Collected (Select one) Physical Limitations 1 Participant III/ Emergency 2 Defective Collection Kit 3 Communication Problem 4 No Time 5 Other Specify___________________ 96 Refused 97
VSL-0001		Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Collected (Select one) Physical Limitations 1 Participant III/ Emergency 2 Defective Collection Kit 3 Communication Problem 4 No Time 5 Broken slide 6 Other Specify___________________ 96 Refused 97
T3 First or T3 Prior ONLY pH value: |__| |__| pH units Note: Record pH value before creating the slide.
Vaginal Swab Collection Comment:____________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Initials QC

_________