B.12 Saliva Collection and Transport Form

B.12 Saliva Collection and Transport Form
Parental Mental Health

PMH Saliva Collection and Transport Form

INSTRUCTIONS: This form is to be completed when a PMH Interviewer collects the saliva specimen and
transports it to the study office.
Part A: Administrative

1.

Recruitment Location: ________________________________________________

2.

Interviewer Name:____________________________________________________

Part B: Biospecimen Collection and Transport Data Elements
3.

Date of saliva sample collection:

Time of Saliva sample collection:

|__|__|/|__|__|/|__|
2_ 0 |__|__|
M

M

D

D

Y

Y

Y

Y

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

H

M

M

AM
PM

Fill in Specimen IDs, or place a Specimen ID label in the appropriate box in the section below.
Specimen Type

4. Specimen ID

5. Transport Temperature

______

°C

Saliva

6. Comments about Collection or Transport:

_______________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________

PMH Saliva Collection and Transport Form.V1.08.06.14