A.2.3.m1 Survey

Appendix A A.2.3.m–0

OMB#: 0925:xxxx

Expiration Date: xx/xxx

National Children’s Study

Adult Hair Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__| Time collection started: |__|__|:|__|__| 1 am 2 pm Time collection stopped: |__|__|:|__|__| 1 am 2 pm	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 Safety Exclusion 10 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 Visit type P1 T1 Mom T1 Prior T1 Dad T3 First T3 Prior
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___| Site ID: |___|___|___|___| Visit location: 1 Home 2 Clinic/Office Participant’s age |__|__| years
Part B: Hair Collection Questions
1) Do you have a hair weave or use a wig? 1 Yes (Go to Part C) 2 No 97 Refuse 98 Don’t Know
2) Has your 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
3) Has your 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

4) Have you used shampoo or conditioner on your hair in the last 24 hours? 1 Yes 2 No (Go to Q 6) 97 Refuse (Go to Q 6) 98 Don’t Know ( Go to Q 6)
5) Have you 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
6) Have you used other hair care products? 1 Yes, Specify __________________ 2 No 97 Refused 98 Don’t Know
Part C: Hair Collection
Kit ID: (Affix Pre-printed Hair Kit ID Label Here)
HRC-0001	Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Collected (Select one) Participant III/Emergency 1 Defective Collection Kit 2 Communication Problem 3 No Time 4 Quantity Not Sufficient 5 Hair Weave/ Wig 6 Other (Specify)___________________ 96 Refused 97
Location of hair collection Back of neck 1 Multiple sites 2
Hair Comment: __________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Initials QC

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