OMB Control Number: 0925-0593
Expiration Date: 07/31/2013
Environmental Tap Water TWF Participant Collect SAQ, Phase 2e
Environmental Tap Water Pharmaceutical (TWF) Participant Collect SAQ
(EH, PB, HI) V1.0
Event: |
Pregnancy Visit 1 |
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Participant: |
Pregnant Woman |
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Domain: |
Environmental |
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Type of Document: |
Self-Administered Questionnaire |
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Recruitment Groups: |
(EH, PB, HI) |
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Tap Water TWF Collection
Follow the instructions in your booklet when collecting the TWF sample.
1
. How many bottles did you fill?
3 (GO TO QUESTION 4)
2 (GO TO QUESTION 2)
1 (GO TO QUESTION 2)
0 (GO TO QUESTION 3)
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2 . Why did you fill fewer than three bottles? Supplies missing from kit Didn’t have time Couldn’t schedule pick-up Other, specify _____________________ |
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(GO TO QUESTION 4)
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3 . Why didn’t you collect any bottles?
Supplies missing from kit Didn’t have time Couldn’t schedule pick-up Decided not to collect sample Other, specify ______________________ (END FORM)
4. TWF sample IDs: AFFIX LABEL FOR EACH BOTTLE YOU FILLED
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Affix TWF Bottle #3/3 Label here |
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5
. What date did you collect the TWF sample?
2 0
Date: //
m m d d y y y y
6
. What day of the week did you collect the TWF sample?
Monday Thursday Saturday
Tuesday Friday Sunday
Wednesday
7
. Where was the TWF sample collected?
Kitchen tap
Bathroom sink/tub
Outside spigot/pump
Other, specify______________________
Prefer not to answer
Don’t know
8
. Is the water filtered? For example do you have a drinking water filter such as a Brita filter on the faucet where you collected the sample?
Yes Prefer not to answer
No Don’t know
9
. Is the tap water from your own household well?
Yes Prefer not to answer
No Don’t know
10. When you collected the TWF sample did you handle or consume any of the following:
M
ARK ALL THAT APPLY
Caffeinated foods or beverages
Tobacco products
Antibacterial soaps lotions or hand sanitizers
Cleaning products
Prescription drugs
Over-the-counter medications
Prefer not to answer
Don’t know
1
1. Did you have any problems collecting the TWF sample?
M
ARK ALL THAT APPLY
No problems
Lost ice packs
Lost foam inserts
Lost labels
Other, specify______________________
Prefer not to answer
Don’t know
Thank you very much for collecting the TWF sample and completing this questionnaire! All of your answers are very important.
Please help us by looking at each question again to make sure that you...
Did not skip any questions, and
Marked out the wrong answer and marked the right answer if you made any changes.
Public reporting burden for this collection of information is estimated to average 10 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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Elizabeth Boyle |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |