Blood Draw Form

Attachment 3.12

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

Blood Draw Form

Form Approved

OMB No. 0923-XXXX

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

Exp. Date xx/xx/20xx

Study ID#:

Before we can take your blood we need to ask you a few questions whether you can provide blood sample.

Do you have hemophilia? Yes No

Have you received any chemotherapy in the last four weeks? Yes No

Do you have active sores, disease, or other problem on your arm/shoulder

that could prevent us from taking your blood sample*? Yes No

[IF FEMALE LESS THAN 60 YEARS] Are you currently pregnant? Yes No

* This may include gauze dressings, casts, edema, paralysis, tubes, open sores or wounds, withered arms or limbs missing, damaged, sclerosed or occluded veins, allergies to cleansing reagents, burned or scarred tissue, shunt or intravenous lines on both arms. Please check and review all with the participant.

[IF THE PARTICIPANT RESPONDED ‘YES’ TO ANY OF THE ABOVE QUESTIONS, THEY SHOULD BE EXCLUDED FROM THE BLOOD DRAW. PLEASE SEE STUDY COORDINATOR IMMEDIATELY.

SENIOR SUPERVISING NURSE WILL MAKE THE DECISION WHETHER A PARTICIPANT WITH ANY TYPE OF SHOULDER LESIONS CAN SAFELY PROVIDE A BLOOD SAMPLE]

We also want to ask you a few questions as a precaution.

Are you on blood thinning medication? Yes No

Are you on diabetes medication or insulin? Yes No

When was the last time you ate? Was it at least eight hours ago? Yes No

Public reporting burden of this collection of information is estimated to average 2 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).

[IF NO] How long ago did you eat? _____:_____ (hours and minutes)

. . . . and what did you eat? ________________________________________________________

[IF THE PARTICIPANT ANSWERED ‘YES’ TO ANY OF THE ABOVE QUESTION PLEASE SEE STUDY COORDINATOR AND SUPERVISIGN NURSE TO MAKE SURE THEY CAN SAFELY PROVIDE BLOOD SAMPLE]

Do you weigh less than 110 lbs? Yes No

[IF YES, COLLECT NO MORE THAN 50 ML OF BLOOD]

[IF NO BUT APPEARS BELOW 110 LBS, CHECK THE BODY MEASUREMENT FORM. IF NOT AVAILABLE, WEIGHT THE PARTICIPANT BEFORE THE BLOOD DRAW TO MAKE SURE]

Result of the Blood Draw (mark one) Volume

□ Complete (125-mL)

□ Partial (_______-mL)

□ Unable to collect

Date:______________ Time: _____:_____ AM PM

Code Partial/Inability to Collect (circle one)

Reason for partial or inability to collect blood:

1. Pregnant

2. Medical (e.g. patient frail, weak, lost consciousness)

3. Less than 110 lbs

4. Refused

5. Other (describe) ______________________________

Interviewer/Phlebotomy Comment:

NOTES: Care should be used in drawing blood from all subjects. Common adverse effects include bruising, bleeding, and fainting. Please ask all participants whether they prefer to lie down to have blood drawn.

Ask everyone if they tend to faint when giving blood. Suggest they sit down for five minutes after giving blood.

Fasting diabetic participants who use insulin will be given priority appointments for their blood draw.

Light snacks will be provided following blood collection.

See Protocol Appendix B.4. for further details on collecting blood sample.