1 Survey

Appendix A A.2.3.l.2–4

National Children’s Study

Adult Blood Data Collection Form-T1 Mom

(Only for use when CHITA is not available)

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__| Data Collector ID: |___|___|___|___| Visit location: Home 1 Clinic/Office 2	Section Status (Select one) Complete 1 Partial Complete 2 Not Done 3 Reason for Not Done/Partial (Select one) SP Refusal (Go to Part D) 1 SP III/ Emergency 3 No Time 4 Safety Exclusions (Go to Part D) 10 Physical Limitation (Go to Part D) 11 Quantity Not Sufficient 14 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
Time kit opened: |__|__|:|__|__| am 1 pm 2 Place Adult Blood Collection –T1 Mom or Saliva BNC Collection Kit Label Here Time collection stopped: |__|__|:|__|__| am 1 pm 2
Part B: Blood Pre-Screening Questions (Ask these questions at all visits when blood is drawn.)
1) Do you have hemophilia or any bleeding disorder? Yes (Go to Part D) 1 No 2 Refused 97 Don’t know 98
2) Do you take any blood thinning medication, such as Coumadin or warfarin? Yes (Go to Part D) 1 No 2 Refused 97 Don’t know 98
3) Have you had cancer chemotherapy within the past 4 weeks? Yes (Go to Part D) 1 No 2 Refused 97 Don’t know 98
4) Have you had any problems with a blood draw in the past? Yes 1 No (Go to Part C) 2 Refused (Go to part C) 97 Don’t know (Go to Part C) 98
5). What problems did you 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 98

Part C: Blood Collection Tubes
LP01 3mL Lavender Prescreened	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6	Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
RD01 10 mL Red Top 01	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6	Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
RD04 10mL Red Top 04	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6	Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
RD03 10 mLRed top 03 SST	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6	Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97

LV03 Lavender Top 03 6 mL EDTA	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6		Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
LV02 Lavender Top 02 PPT	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6		Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
LV04 Lavender Top 04 P100	Collected 1 Partial Collected 2 Not Colleted 3
	Reason for not collected or partial: Equipment failure 3 Fainting 4 Light-headedness 5 Hematoma 6		Bruising 7 Vein collapsed during the procedure 8 Other, Specify_________ 96 Refused 97
Blood Collection Comment:________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Part D Saliva BNC Collection (Only use if blood collection is refused or not possible)
Because you have hemophilia, are taking blood thinning medication, have had chemotherapy recently, or refused the blood draw, 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? Yes 1 No 2 BE SURE TO REVIEW SALIVA SAMPLE COLLECTION INSTRUCTIONS WITH THE PARTICIPANT
Collected 1 Partial Collected 2 Not Colleted 3
Reason not done or partial: No time 1 SP Ill/Emergency 2 Equipment failure 3		Other, Specify_________ 96 Refuse 97 Could not obtain 99
Saliva Comments: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
Part E: Transport Temperatures
Time placed in cold compartment for transport to SPSC: |__|__|:|__|__| am 1 pm 2 Cold Compartment temperature: |__|__|.|__| °C Cold Compartment Upper (15 °C) Temperature Threshold Monitor has been activated Yes 1 No 2 Cold Compartment Lower (0 °C)Temperature Threshold Monitor has been activated Yes 1 No 2 Ambient Compartment Temperature Threshold Monitor has been activated Yes 1 No 2 (The ambient compartment is only used for P100 tubes that have not been centrifuged)

4 Revised 9/8/08