24-Hour Urine Collection Form

24-Hour Urine Collection Form

Public reporting burden of this collection of information is estimated to average 50 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 Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

General Instructions:

Name: _________________________ (surname) ­_________________________ (first name)

Clinic Phone Number: __________________________________________________________

Specimen Collection Instructions

1. On the assigned day of collection, empty the contents of your bladder into the lavatory on that morning. Note the time and date in the space provided below.

Starting time: __________ (hr) __________ (min) __________ (am)

Date: __________ (month) __________ (day) __________ (year)

From this time on, collect all the urine that you pass during the day and the following morning in the plastic urine collection bottle (s). When you get up in the morning, empty the contents of your bladder into the plastic container and note the time and date in the space provided below.

Finishing time: __________ (hr) __________ (min) __________ (pm or am)

You may store the specimen in any convenient location until your next visit to the Center. Storage in a cool temperature is preferable. Be sure to attach this sheet to your urine specimen bottle and with a rubber band. Remember to bring the urine specimen bottle/instruction sheet to your clinic visit on __________________ and give both form and urine collection bottle (s) to the clinic manager __________________ at your next visit to the center.

Please remember to bring this sheet as well as your urine specimen. Good Luck!