Form 2 Clinical Exam Saliva Collection Log

OMB#0925-0626 EXP. 01/2014

Saliva Sample Log
Date of
Samples

□□/□□/ □□□□

Month
Day
Year
Reminder: Write the exact date and time you took the sample on the saliva tube!

Wake
Up

Sample 1: (Please take sample while still in bed!)
a.) actual time
sample taken

b.)

□○□
:
□
□
○ ○ 
AM

PM

BEFORE taking
this sample, did
you do any of
the following?

○○Brushed teeth?
○ Eaten anything?
○ Drunk anything?
○ Exercised?

Additional Questions for beginning of day:

c.) do you feel
happy, excited,
or content
right now?

○○Not at all
○ Somewhat
○ Very much
○ Extremely

d.) do you feel
worried, anxious,
or fearful right
now?

e.)

Problems or
concerns?

○○Not at all
○ Somewhat
○ Very much
○ Extremely

□□:□□○ ○
□□:□□○ ○
□□:□□○ ○
□□
□□:□□

□□:□□
AM

1. Around what time did you fall asleep last night?

AM

2. What time do you usually wake up?

AM

3. What time did you wake up today?

4. How many times did you wake up last night?

PM

PM

PM

Times

5. How many hours and minutes of sleep did you get last night?

6. How many hours and minutes of sleep do you usually get a night?

Hrs

Mins

Hrs

Mins

PLEASE NOTE: Take the next sample 45 minutes after the first. It is fine to brush your teeth and eat your
breakfast in the first 25 minutes after taking sample 1, but please avoid doing these in the 20 minutes right
before taking sample 2. Please avoid ALL caffeinated beverages until AFTER you have taken
sample 2.

+45min

Sample 2: (45 minutes after you wake up)
a.)

Actual time

b.)

sample taken

□○□
:
□
□
○ ○ 
AM

PM

BEFORE taking
this sample, did
you do any of the
following?

○○Brushed teeth?
○ Eaten anything?
○ Drunk anything?
○ Exercised?

c.) do you feel
happy, excited,
or content
right now?

○○Not at all
○ Somewhat
○ Very much
○ Extremely

d.) do you feel
worried, anxious,
or fearful right
now?

e.)

Problems or
concerns?

○○Not at all
○ Somewhat
○ Very much
○ Extremely

Now that you’ve taken sample 2, it is fine to drink coffee.
U.S. Department of Health and Human Services National Institutes of Health National Institute of Environmental Health Sciences

Page 1

Saliva Sample Log
+4hrs

Sample 3: (About 4 hours after you wake up)
a.)

Actual time

b.)

sample taken

□○□
:
□
□
○ ○ 
AM

PM

BEFORE taking
this sample, did
you do any of the
following?

○○Brushed teeth?
○ Eaten anything?
○ Drunk anything?
○ Exercised?

c.) do you feel
happy, excited,
or content
right now?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

d.) do you feel
worried, anxious,
or fearful right
now?

e.)

Problems or
concerns?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

+10hrs

Sample 4: (About 10 hours after you wake up)
a.)

Actual time

b.)

sample taken

BEFORE taking
this sample, did
you do any of the
following?

○○
○
□○□
:
□
□
○ ○  ○
AM

PM

○

Brushed teeth?
Eaten anything?
Drunk anything?
Exercised?

c.) do you feel
happy, excited,
or content
right now?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

d.) do you feel
worried, anxious,
or fearful right
now?

e.)

Problems or
concerns?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

Bed
time

Sample 5: (Before bed and BEFORE brushing!)
a.) actual time
sample taken

b.)

□○□
:
□
□
○ ○ 
AM

PM

BEFORE taking
this sample, did
you do any of the
following?

○○Brushed teeth?
○ Eaten anything?
○ Drunk anything?
○ Exercised?

c.) do you feel
happy, excited,
or content
right now?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

d.) do you feel
worried, anxious,
or fearful right
now?

e.)

Problems or
concerns?

○○Not at all
○○Somewhat
○○Very much
○○Extremely

Additional Questions for end of day:
1. Did you smoke any cigarettes today?

○ No ○ Y

es

2. Did you drink any alcoholic beverages today?

○○

No

○

Yes

How many cigarettes did you smoke today?

□□

3. Did you take any drugs or medications today?

○○No ○ Yes

Please list the names of all drugs or medications you took today:

4. Did you do any vigorous exercise today, exercise that increased your heart rate or made you sweat?

○○Yes
○○No

What time did it begin?

□□:□□ ○
□□□

AM

○PM

How long did you exercise for?
minutes

Public reporting burden for this collection of information is estimated to average 5 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 (0925-0626). Do not return the completed
form to this address.