Medication Form

Attachment 3.10

Anniston Community Health Survey: Follow-up Study and Dioxin Analyses

Medications Form

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Note: It is important to ask the participants to bring in all medications used regularly during the past two weeks before coming in for the physical measurements & blood draw. This includes both Over-the-Counter and Prescription Medications. These include pills, liquid medications, skin patches, eye drops, salves, inhalers and injections, as well as cold or allergy medications, herbal remedies, aspirin, ointments, vitamin supplements, Tylenol and Motrin are all examples. They could possibly affect the test and lab results.

1. Ask the participant about all medications, including over the counter, herbal remedies, fish oil, and vitamin or dietary supplements.

2. If the participant refuses to bring the medications or to allow you to record them, write “refused” on the medications form and proceed to next step.

3. Provide dose (e.g. 50 mg), frequency (e.g. twice a day), and route (e.g. by mouth). Add lines as necessary.

4. Ask about any medications left at home, such as those needing refrigeration.

	Study ID#	Name of Medication	Dose	Frequency	Route	Last Dose
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Public reporting burden of this collection of information is estimated to average 3 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).