1 Survey

Appendix A A.2.3.m–3

OMB#: 0925:xxxx

Expiration Date: xx/xxx

National Children’s Study

Child Hair Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__|	Site ID: |___|___|___|___| Participant’s age |__|__| months Visit type 12 Months 36 Months 60 Months
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___|
Part B: Hair Collection Questions
1) Does ______ (child’s name) have a hair weave or use a wig? 1 Yes 2 No (Go to Q 3) 97 Refuse (Go to Q 3) 98 Don’t Know ( Go to Q 3)
2) Is ______ (child’s name) able to provide a hair sample today? 1 Yes 2 No (END) 97 Refuse (END) 98 Don’t Know (END)
3) Has ______ (child’s name) hair been treated with a hair dye or hair color within the last 3 months? 1 Yes 2 No 97 Refuse 98 Don’t Know
4) Has ______ (child’s name) hair been given a permanent or treated with a hair straightener within the last 3 months? 1 Yes 2 No 97 Refuse 98 Don’t Know
5) Has ______ (child’s name) used shampoo or conditioner on his/her hair in the last 24 hours? 1 Yes 2 No (Go to Q 7) 97 Refuse (Go to Q 7) 98 Don’t Know ( Go to Q 7)

6) Has ______ (child’s name) used any of the following dandruff shampoos or conditioners in the last 24 hours? 1 Head and Shoulders 2 Denorex 3 Dermarest 4 Selsun Blue 96 Other, Specify __________________ 97 Refused 98 Don’t Know
7) Has ______ (child’s name) used other hair care products? 1 Yes, Specify __________________ 2 No 97 Refused 98 Don’t Know
Part C: Hair Collection
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
Hair collection item ID |___|___|___|___|___|___|___|___|___|___|___|___|	Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Done/Partial (Select one) Physical Limitations 1 Participant III/Emergency 2 Defective Collection Kit 3 Communication Problem 4 No Time 5 Quantity not sufficient 6 Other Specify___________________ 96 Refused 97 Don’t know 98
Location of hair collection Back of neck 1 Multiple sites 2
Hair Comment: __________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.