Form No number No number Laboratory visit

Form Approved
OMB No. 0920-0736
Exp. Date 3/31/2010

DATE: _________________
ID #_________________
ID Number

HSB STUDY DATA COLLECTION-VISIT #1
Yes
No

Own Cigarette Brand

________________

Valid ID

Yes

Time Last Smoked

___:___

Consent Form

Yes

No

Collect 4 Cigarette Butts from Home

Yes

No

Smoking History Questionnaire

Yes

No

Collect Urine Sample

Yes

No

No
AM

PM

(no time limit)

LIFESHIRT: Give participant appropriate-sized vest (women need not remove undergarments)
Apply Electrodes (if needed)

Yes

No

Explain event marker

Yes

No

Confirm system works properly

Yes

No

Collect 2 Saliva Samples

Yes

No

PATIENT MONITOR
Apply Electrodes (if needed)

Yes

No

Apply blood pressure cuff

Yes

No

Place finger in SPO2 sensor

Yes

No

Confirm system works properly

Yes

No

Public reporting burden of this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0736)

Form Approved
OMB No. 0920-0736
Exp. Date 3/31/2010

DATE: _________________
ID #_________________
HSB STUDY DATA COLLECTION-VISIT #1 (CONTINUED)
Blood Pressure

________________

Heart Rate

________________
BPM

Carbon Monoxide

LEVEL:__________

TIME:
___:___

AM

PM

Prior to smoking, turn on video camera, have participant hold card with ID
number, date and time for a couple of seconds
Remind participant to press the even marker EVERYTIME they take a puff

CRESS – Begin smoking

Start TIME:

___:___

AM

PM

___:___ AM
PM
CRESS – Finish smoking
Stop TIME:
After smoking, have participant press event marker three times in a row

Blood Pressure

________________

Heart Rate

________________
BPM

Carbon Monoxide

LEVEL:__________

Length of Subject’s Own Brand

___________mm

(filter and overwrap)

Length of entire cigarette

___________mm

UPC Number

________________

Reimburse

Amount
$_______________

TIME:
___:___

AM

PM

Address questions; provide cessation info if requested and thank.

NOTES:

Public reporting burden of this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0736)

Form Approved
OMB No. 0920-0736
Exp. Date 3/31/2010

DATE: _________________
ID #_________________
ID Number

HSB STUDY DATA COLLECTION-VISIT #2
Yes
No

Own Cigarette Brand

________________

Valid ID

Yes

Time Last Smoked

___:___

Consent Form

Yes

No

Collect 4 Cigarette Butts from Home

Yes

No

Smoking History Questionnaire

Yes

No

Collect Urine Sample

Yes

No

No
AM

PM

(no time limit)

LIFESHIRT: Give participant appropriate-sized vest (women need not remove undergarments)
Apply Electrodes (if needed)

Yes

No

Explain event marker

Yes

No

Confirm system works properly

Yes

No

Collect 2 Saliva Samples

Yes

No

PATIENT MONITOR
Apply Electrodes (if needed)

Yes

No

Apply blood pressure cuff

Yes

No

Place finger in SPO2 sensor

Yes

No

Confirm system works properly

Yes

No

Public reporting burden of this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0736)

Form Approved
OMB No. 0920-0736
Exp. Date 3/31/2010

DATE: _________________
ID #_________________
HSB STUDY DATA COLLECTION-VISIT #2 (CONTINUED)
Blood Pressure

________________

Heart Rate

________________
BPM

Carbon Monoxide

LEVEL:__________

TIME:
___:___

AM

PM

Prior to smoking, turn on video camera, have participant hold card with ID
number, date and time for a couple of seconds
Remind participant to press the even marker EVERYTIME they take a puff

CRESS – Begin smoking

Start TIME:

___:___

AM

PM

___:___ AM
PM
CRESS – Finish smoking
Stop TIME:
After smoking, have participant press event marker three times in a row

Blood Pressure

________________

Heart Rate

________________
BPM

Carbon Monoxide

LEVEL:__________

Length of Subject’s Own Brand

___________mm

(filter and overwrap)

Length of entire cigarette

___________mm

UPC Number

________________

Reimburse

Amount
$_______________

TIME:
___:___

AM

PM

Address questions; provide cessation info if requested and thank.

NOTES:

Public reporting burden of this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0736)