Supplemental documents

OMB0116_Data Collection Form - Cigarette Lighter.doc

Safety Standard for Cigarette Lighters

Supplemental documents

OMB: 3041-0116

Document [doc]
Download: doc | pdf


OMB control number 3041-0116


[INSERT COMPANY NAME]


DATA COLLECTION FORM FOR CIGARETTE LIGHTER CHILD TEST PANEL


C onducted for: Lighter:


Company Name Model Name / Number


all entries below this line must be made in black or blue ink by the tester whose name and signature appear below


Test Site:

Name Street Address City, State



Test Date: Tester Name: Tester Signature:

(mo/day/yr) Please Print


Pair A


Pair B


Pair C


LEFT

RIGHT


LEFT

RIGHT


LEFT

RIGHT

Child’s Full Name

First:


Last:







Proper informed consent obtained?


YES ____ NO ____


YES ____ NO ____


YES ____ NO ____


YES ____ NO ____


YES ____ NO ____


YES ____ NO ____

Birth Date:

(mo/day/yr)

| |

| |

| |

| |

| |

| |

Age (months):







Sex (M / F):







Surrogate Lighter #:







Surrogate lighter works?

Before:

After:

YES ____ NO ____


YES ____ NO ____

YES ____ NO ____


YES ____ NO ____

YES ____ NO ____


YES ____ NO ____

YES ____ NO ____


YES ____ NO ____

YES ____ NO ____


YES ____ NO ____

YES ____ NO ____


YES ____ NO ____

Test Start Time:

: A.M. ____ P.M. ____

: A.M. ____ P.M. ____

: A.M. ____ P.M. ____

Operation:

(001-600 sec. or None)







Tester Comments and Observed Method(s) of Operation / Attempted Operation (see codes):








Method of operation: 1 – Used one hand, thumb 2 – Used one hand, index finger 3 – Used two hands, thumb 4 – Used two hands, index finger 5 – Other (specify in tester comments field)

Data collection in accordance with 16 C.F.R. Part 1210.4(g)


File Typeapplication/msword
File TitleCOMPANY NAME
AuthorJason R. Goldsmith
Last Modified ByPreferred Customer
File Modified2006-03-31
File Created2005-12-15

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