Form 6 Att.8 Heart Rate Monitor Log

Attachment 8

Heart Rate Monitor Log	OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 35 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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 (####-####).

H

iDATA

Study

ID: _____________

eart Rate Monitor Log

Day	Date	Day (Mon.- Sun)	Time out of bed in the morning	Time put monitor on	Time monitor removed	Time into bed for the night	List times during the day the monitor was not worn. Include reason not worn.
1	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
2	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
3	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
4	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
5	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
6	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm
7	/ /		___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm	___ : ___ am/pm ___ : ___ am/pm

Staff notes: ________________________________________________________________________________________________