Form 1 Urine Collection

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 3d c - English
PATH Study Data Collection Instruments:
Biospecimen Collection Forms - Urine
June 18, 2013

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

RS8d –Urine Data Collection Form
Respondent ID (Text Readable Barcode)
DCN
OMB Control Number: 0925-0664
Expiration Date: 11/30/2015
Date Printed

PATH Study Urine Data Collection Form

Interviewer-Administered

Part A: Administrative

Part C: Urine Collection Status

1.

1. Collection Status (Mark one):
Collected (End)
Not Collected
Attempted, Not Collected

Staff ID: Preprinted

2. Today’s Date:
|__|__|/|__|__|/|__|__|__|__|
M

M

D

D

Y

Y

Y

Y

2. Reason not collected (Mark one main reason):
Respondent refused, specify:
______________________
Respondent refused, unwilling to give reason
Respondent ill/emergency
Unable to urinate
No time/busy
Uncomfortable with self-collection procedures
Defective/missing collection supplies
Physical limitation, specify: ______________________
Other, specify: _________________________________

3. Urine Collection:
Agreed
Not Agreed (Go to Part C)
4. Urine Kit ID:
(Place Label Here)

Part B: Urine Collection Questions

1. When was the last time you urinated?
Date: |__|__|/|__|__|/|__|__|__|__|
M

M

D

D

Y

Time: |__|__| : |__|__|
H

H

M

Y

Y

2. When was the last time you had anything to eat or
drink other than water?
Date: |__|__|/|__|__|/|__|__|__|__|

Y

a.m.

p.m.

M

Refused

M

M

D

D

Y

Time: |__|__| : |__|__|

Don’t Know

H

Refused

H

M

Y

Y

Y

a.m.

p.m.

M

Don’t Know

3. Have you had cancer chemotherapy within the past 2 weeks?
Yes
No
Refused
Don’t Know
Part D: Urine Collection Results

1. Collection time:
|__|__| : |__|__|
H

H

a.m.

p.m.

M M

2. TrekView temperature monitor activated and
included with specimen in amber transport bag?
Yes

3. Time specimen and TrekView temperature monitor placed in shipping container:
|__|__| : |__|__|
H

H

M M

a.m.

p.m.

Population Assessment of Tobacco and Health (PATH) Study (NIDA)
Part E: Comments



GO TO TOP OF FORM AND COMPLETE PART C URINE COLLECTION STATUS

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 (0925-0664). Do not return the completed form to this address.