1 Survey

Appendix A A.2.3.l–22

For Office Use Only

Participant # __ __ __ __ __

#__ __ __ __ __

National Children’s Study

Child 12 Months Blood Draw Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__|		Section Status (Select one) Complete 1 Partial Complete 2 Not Done 3 Reason for Not Done/Partial (Select one) Safety Exclusion 1 Physical Limitations 2 Participant III/Emergency 3 Equipment Failure 4 Communication Problem 5 No Time 6 Other Specify___________________ 96 Refused 97 Don’t Know 98
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___| Site ID: |___|___|___|___| Participant’s age |__|__| months
Part B: Blood Collection Questions (Ask these questions at all visits when blood is drawn for the child.)
1) Does _____ (child’s name) have hemophilia or any bleeding disorder? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
2) Does _____ (child’s name) take any blood-thinning medication, such as Coumadin or Warfarin? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
3) Has _____ (child’s name) had cancer chemotherapy within the past 4 weeks? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
4) Has _____ (child’s name) had any problems with a blood draw in the past? 1 Yes 2 No (Go to Q 6) 97 Refuse (Go to Q 6) 98 Don’t Know ( Go to Q 6)
5). What problems did _____ (child’s name) 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 97
6) When was the last time _____ (child’s name) had anything to eat or drink? |__|__|:|__|__| 1 am 2 pm
7) Is this a fasting blood sample? (If the answer to Question 6 is less than 8 hours ago the answer is No.) 1 Yes 2 No
Part C Saliva Collection (Only use if blood collection is refused or not possible)
8) Because your child {has hemophilia; is taking blood thinning medication; has had chemotherapy recently} we will not be able to draw his/her blood at this time. Several measures that are performed in blood can be measured in saliva. Is _____ (child’s name) able to provide a saliva sample? 1Yes 2 No BE SURE TO REVIEW SALIVA SAMPLE COLLECTION INSTRUCTIONS WITH THE PARTICIPANT
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
9) Saliva collection status 1 Collected 2 Not Collected Reason for not collecting No Time 1 Participant III/Emergency 2 Equipment Failure 3 Other Specify___________________ 96 Refused 97 Don’t Know 98 Could Not Obtain 99
Saliva Comments: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
Part D Tubes to be drawn for Child at 12 Months
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
Red top (5ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5		Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97 Don’t Know 98
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Red top (5ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5			Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97 Don’t Know 98
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Lavender top (6ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5			Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97 Don’t Know 98
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Pre-screened lavender top (3ml)	1 Collected 2 Not Collected Reason for not collecting: No Time 1 Participant Ill/Emergency 2 Equipment Failure 3 Fainting 4 Light-Headedness 5			Hematoma 6 Bruising 7 Vein Collapsed During the Procedure 8 No Suitable Vein 9 Other, Specify_________ 96 Refuse 97 Don’t Know 98
Tube barcode	|___|___|___|___|___|___|___|___|___|___|___|___|
Blood Collection Comment:________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

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