SEARCH Specimen Collection Form

SEARCH for Diabetes in Youth Study

Att 4a4_specimen collection form registry

SEARCH Specimen Collection Form

OMB: 0920-0904

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6. Have you taken any other diabetes medications in the last 8 hours?
1‰

Yes (if YES, ask which medications were taken and mark by the appropriate list of

2‰

No

medications below; then answer question 6a at the bottom of the page)

Other diabetes medications:

1‰

Acarbose
Actos
Avandament
Avandia
Glucophage
Glyset
Metformin
Miglitol
Precose
Pioglitazone
Rosiglitazone

Acceptable medications

Amaryl

Byetta

2‰

1‰

Chlorpropamide
DiaBeta
Diabinese
Exenatide
Glimepiride
Glipizide
Glucotrol
Glucovance
Glyburide
Glynase
Januvia
Liraglutide
Micronase
Nateglinide
Prandin
Pramlintide
Repaglinide
Sitagliptin
Starlix
Symlin
Tolazamide
Tolbutamide
Victoza

Time:
Hour

Minute

‰ AM
‰ PM

NOT acceptable if taken within 8 hours prior to
fasting blood sample
Proceed with blood draw and try to re-schedule
a fasting re-draw visit.

Other diabetes medications: (specify)

IF UNACCEPTABLE INSULIN OR ORAL MEDICATION TAKEN, PROCEED WITH BLOOD DRAW AND TRY TO
SCHEDULE A FASTING RE-DRAW VISIT.
6a.

If a re-draw visit is necessary, has Patient agreed? 1‰

SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10

Yes

2‰

No

Page 2

7. Have you had anything to eat or drink in the last 8 hours?
1‰

Yes

7a. if YES, ask the Patient what they had

to eat or drink. Describe what they had to
eat or drink.

7b. if Patient consumed non-allowable food

‰AM ‰PM

Time:

or drink, record most recent time

Hour

Minute

IF FASTING LESS THAN 8 HOURS, PROCEED WITH BLOOD DRAW AND TRY TO
SCHEDULE A FASTING RE-DRAW VISIT.
7c.
2‰

If a re-draw visit is necessary, has Patient agreed? 1‰ Yes

2‰

No

No

8. Glucose meter reading:

(May use drop from blood collected with venipuncture samples)

If glucose is > 300 mg/dl, perform urinary ketone check and record.
8a. Urine ketones:

1‰

Negative

2‰

3‰

Trace/small

Moderate

4‰

9. Were any of the following symptoms observed or reported by the Patient?

Large

1‰

5‰

Yes

(If YES, check all that apply):

1‰

Abdominal pain

1‰

Diaphoresis (excessive sweating)

1‰

Lightheadedness

1‰

Nausea and or vomiting

1‰

Seizure

1‰

Tremors or trembling

1‰

Loss of consciousness due to low blood glucose

1‰

Loss of consciousness due to phlebotomy (fainting)

1‰

Blood glucose is < 45 mg./dl.

1‰

Blood glucose is > 300 mg./dl. with moderate or large ketones

1‰

Blood glucose is > 500 mg./dl. with or without ketones

1‰

Other (specify):

Unable to obtain

2‰No

10. Comments?
1‰
2‰

Yes (if YES, describe) :
No comments

NOTE: Complete SEARCH Unanticipated Occurrence/Condition Reporting Form if
any of the below presents:
•
•

seizure
loss of consciousness due to low blood glucose

SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10

Page 3

11. Specimen obtained
by:

(code)

12. Date specimen

obtained:

Month

Day

13. Time specimen

Year

‰ AM / ‰ PM (check one)

collected:

Hour

Minute

Please instruct the Patient to take medication/insulin and provide a breakfast to the Patient.

FOR STUDY USE ONLY
Date Completed

Completed by
Month

Day

Year

Date Reviewed

Reviewer Code
Month

Day

Year

Date Entered
Month

Day

Year

SEARCH 3 Registry and Cohort Studies - Specimen Collection form 11-01-10

Data Entry
Code

Page 4


File Typeapplication/pdf
File TitleMicrosoft Word - Specimen Collection - Reg and Cohort - 11-01-10 FINAL FINAL FINAL _minor revision 10-29_
Authorstmoxley
File Modified2011-05-10
File Created2010-11-03

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