MN Clinic Visit

Biomonitoring of Great Lakes Populations Program

Att5f_MN_ClncVstForm_20120131

MN Clinic Visit Form

OMB: 0923-0044

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Attachment 5f. (MN7.3) Clinic Visit Form

Reading level 0.9 for questions

Shape1

Study ID FORM APPROVED

OMB No. 0923-XXXX

Expiration Date: MM/DD/ YYYY

Clinic Visit Form

Body Measurements

Height

_____ feet _____ inches

or ________ cm

Refused

Weight


_______ pounds

or _______ kg

Refused

Waist Circumference

_______ inches

or _______ cm

Refused

Blood Pressure

_______/_______ or

_____ systolic _____ diastolic

Refused

ASK: Have you lost weight in the past 12 months?

  • Yes, How many pounds did you lose? ______ lbs

  • No

  • DK

  • Refused


ASK: Have you gained weight in the past 12 months?

  • Yes, How many pounds did you gain? ______ lbs

  • No

  • DK

  • Refused


Notes:



Venipuncture Assessment

No draw due to assessment

Reason Unable:

Medical condition, doctor’s advice – cannot reschedule

Temporary condition – able to reschedule

Unwilling/Refused

Notes:





Public reporting burden of this collection of information is estimated to average 1 minute 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).



Blood Sample

Collected

Not Collected


___/2 - 10 ml red top tubes


___/2 - 7 ml red top tubes


4 ml purple top tube (EDTA)


___/2 - 2 ml (EDTA) tubes



Draw attempted / less than 27 ml obtained


Unwilling/Refused



Blood collection - Staff initials: __________________

Notes:





Lab Sample ID:



Urine Sample

Urine collected

Time: _________

Not able

Unwilling/Refused

Notes:







Date: __________

Study Staff: _____



Appendix 7.3. page 1


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDavis, Stephanie I. (ATSDR/DHS/HIBR)
File Modified0000-00-00
File Created2021-01-28

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