1 Survey

Appendix A A.2.3.j–7

For Office Use Only

Participant # __ __ __ __ __

#__ __ __ __ __

National Children’s Study

DAY 1: CHILD SALIVA DATA COLLECTION FORM

**Please collect your child’s 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 the child wakes up	_____:_____
Bedtime	Before brushing his/her teeth and at least 1 hour after eating for the last time today	_____:_____

1. Please write down the name of any prescription or over the counter medications that your child has taken today. Please be specific. For example, if he/she took Robitussin DM^®, write Robitussin DM^® not Robitussin^®.

__________________________ ___________________

__________________________ ___________________

__________________________ ___________________

Please feel free to call if you have any questions:

[X at phone #]

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