Form A.2.3.f Survey

Appendix A A.2.3.f.2

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

National Children’s Study

Adult Urine Data Collection Form

(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 1 SP III/ Emergency 3 No Time 4 Physical Limitations 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 collection kit opened: |__|__|:|__|__| am 1 pm 2 Place Adult Urine Kit Label Here Time specimen received: |__|__|:|__|__| am 1 pm 2
Part B: Adult Urine Collection Questions
1) What was the time of your last urination prior to this collection? |__|__| : |__|__| am 1 pm 2 Refused 97 Don’t know 98
2) When was the last time you had anything to eat or drink other than water? |__|__| : |__|__| am 1 pm 2 Refused 97 Don’t know 98
3) How much of what you ate was beef, pork, cod, tuna, or salmon? None 1 One fourth 2 One third 3 One half 4		Three quarters 5 All 6 Refused 97 Don’t know 98
4) Do you take creatine supplements? Yes 1 No 2 Refused 97 Don’t know 98

Part C: Adult Urine Collection
UR01 Urine collection container	Collection Status (Select one) Collected 1 (END) Not Collected 2 Reason for Not Collected (Select one) Quantity Not Sufficient (<40ml) 6 Other Specify___________________ 96 Refused 97
Comments:______________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Data Collector ID for QC

|___|___|___|___|

Public reporting burden for this collection of information is estimated to average 7 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.

Revised 9/8/08