Form 66.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Biospecimen Urine Collection, Phase II

Recruitment Strategy Substudy

Event Name(s):

Biospecimen Urine Instrument (EH, PB, HI) – 1.0

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

Instrument Name(s) and Versions:

Biospecimen Urine Instrument (EH, PB, HI) – 1.0

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Biospecimen Urine Instrument (EH, PB, HI)

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

TABLE OF CONTENTS

CAPI 1

BIOSPECIMEN URINE COLLECTION 1

Biospecimen Urine Instrument (EH, PB, HI)

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

CAPI

Biospecimen URINE COLLECTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

UR0900. You will now collect a urine sample. I will need to ask you some questions before you collect your urine sample.

CONTINUE 01

REFUSED 02 (BL2060)

UR1000. When did you last urinate?

__ __ : __ __

AM. 01

PM. 02

REFUSED 9-97

DON’T KNOW 9-98

DATA COLLECTOR INSTRUCTIONS:

ENTER TIME AS HH:MM AND AM OR PM.

UR1100 When was the last time you had anything to eat or drink other than water?

__ __ : __ __

______/______/____________ MM/DD/YYYY

AM 01

PM. 02

REFUSED 9-97

DON’T KNOW 9-98

DATA COLLECTOR INSTRUCTIONS:

ENTER TIME AS HH:MM and AM OR PM

ENTER TWO DIGIT MONTH, TWO DIGIT DAY, AND FOUR DIGIT YEAR.

UR1200 How much of what you ate was beef, pork, tuna, or salmon?

NONE……………………………………………………………….01

Less than one quarter of the meal…………………………….... 02

One quarter to one half of the meal…………………………….. 03

Less than three quarters of the meal………………………….... 04

Three quarters to all of the meal………………………………… 05

All of the meal……………………………………………………... 06

REFUSED…………………………………………………………..9-97

DON’T KNOW………………………………………………………9-98

UR1300 Do you take creatine supplements?

YES……………………………………………………………….01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

DATA COLLECTOR INSTRUCTIONS:

IF THE PARTICIPANT ASKS, EXPLAIN THAT CREATINE SUPPLEMENTS ARE OFTEN TAKEN BY ATHLETES WISHING TO GAIN MUSCLE MASS.

STATEMENT: Here are your urine collection materials. Please review the instructions with me.

Public reporting burden for this collection of information is estimated to average 15 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 (0925-0593*). Do not return the completed form to this address.