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pdfForm Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx
EPA Pilot Study Add-On
to the
Green Housing Study
Participant Instruction and
Record Book
Public reporting burden of this collection of information is estimated to average 30 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
Page 1 of 42
Day 2
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Page 2 of 42
Day 2
Day 2 Checklist
Use this checklist to mark the completed activities for Day 2
Silicone Band Kept On Child
Sock Samples Collected and Stored
Duplicate Diet Samples Collected and Food Diary Completed
Activity Monitors Placed for the Day and Removed Prior to Sleep
End of Day Activities Completed
Page 3 of 42
Day 2
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Page 4 of 42
Day 2
Silicone Band
1
2
If the band has to be removed or
placed on a different location (wrist to
ankle, etc.), write what was done
below.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Please leave the silicone band on your
child until the field team returns on
Day 5.
__________________________________________________________
__________________________________________________________
__________________________________________________________
Page 5 of 42
Day 2
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Page 6 of 42
Day 2
Duplicate Diet
We need to get a matching amount of food and drink from you. How much children
eat varies. Please try to collect exactly the same amount of food your child eats.
1
2
You need to collect the same amount
of food and drink as your child eats
and drinks on the day after we visited
you.
Include exactly the same amount of
food as your child eats, prepared in
the same way. Remove the peels,
wrappers, bones, etc. just like you
would for your child. If your child only
eats part of the food, only place the
same amount of the food in the
container.
3
4
For example, if your child eats two
slices of orange, place only two slices
of orange in the container.
Put the food in the container marked
Solid Food and drinks in the
container marked Beverages.
Page 7 of 42
Day 2
Duplicate Diet (continued)
5
6
Please describe the food or beverages
and record the time the food was
eaten in the Food Diary on this page.
After the food is placed in the
containers, please store the
containers in your refrigerator until
the field team returns.
Food Diary
List each solid or liquid food your child has
eaten.
Example: Apple Sauce
How Much?
½ Cup
Page 8 of 42
Meal
(Breakfast, Lunch,
Dinner, Snack)
Snack
Day 2
Activity Monitors
1
2
Place the belt with the activity monitor
on your child’s waist. Make sure the
arrow on the monitor is pointing up
toward their head.
Remove the charging plug from the
QSTARZ travel recorder.
3
Please keep the QSTARZ travel
recorder on your child all day. If that is
not possible, place it on something
that is always near your child (for
example a stroller, diaper bag,
backpack).
Write what time it is now in the box
below.
Start Time:
Time
AM / PM
Page 9 of 42
Reason
Day 2
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Page 10 of 42
Day 2
End of the Day
1
2
At the end of the day, remove the belt
with the activity monitor from your
child. Record the time it is now in the
box below.
Re-connect the QSTARZ travel
recorder to the plugged-in charger.
End Time:
AM / PM
3
4
REMINDER!
Collect first morning
void Urine Sample
Place the reminder note on the toilet
or other prominent location. Write the
time of the last void before the
morning void is collected tomorrow in
the box below.
If your child is not toilet trained,
please put one of the diapers from the
sample kit on your child before he or
she goes to bed. Record the time of
the last wet diaper in the box below.
Time:
Time:
AM / PM
Page 11 of 42
AM / PM
Day 2
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Page 12 of 42
Day 3
Day 3 Checklist
Use this checklist to mark the completed activities for Day 3
Silicone Band Kept on Child
Urine Collection Completed and Stored
Activity Monitors Placed for Day and Removed Prior to Sleep
Stool Sample Collected and Stored
End of Day Activities Completed
Page 13 of 42
Day 3
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Page 14 of 42
Day 3
Silicone Band
1
2
If the band has to be removed or
placed on a different location (wrist to
ankle, etc.), write what was done
below.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Please continue to leave the silicone
band on your child until the field team
returns.
__________________________________________________________
__________________________________________________________
__________________________________________________________
Page 15 of 42
Day 3
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Page 16 of 42
Day 3
Urine Collection (Toilet Trained First Morning Void)
1
2
Have your child rinse his or her hands
with water and air or towel dry them.
Put on a pair of purple gloves from the
sample kit.
3
4
When your child is ready to urinate,
remove the cap from the DAY 3 URINE
collection container and place the cap
with the inside up in a safe place
where it is unlikely to be knocked
over. Do not touch the inside of the
container or cap at any time.
Have your child urinate into the
collection container. Collect the entire
amount of urine and assist as
necessary.
Is this a First Morning Void?
Page 17 of 42
□YES
□NO
Day 3
Urine Collection (Toilet Trained First Morning Void - continued)
5
6
Recap the collection container. If the
container is wet, wipe it down with
toilet paper or a paper towel.
Place the collection container in the
zip-lock bag with absorbent material.
Remove excess air from the bag and
seal it.
7
8
Remove the gloves and throw them
away. Write the time the sample was
collected in the box below.
Time:
AM / PM
Place the bag containing the sample in
the cooler as soon as possible after
sample collection.
Page 18 of 42
Day 3
Diaper Urine Collection
1
2
Collect the first wet diaper of the
morning. If the diaper is dirty
(contains stool), use that as the stool
sample (If collected) and place a clean
diaper on your child and collect the
next wet diaper.
Put the diaper inside of the zip-lock
bag labeled Diaper Urine Day 3 and
seal the bag.
4
3
Please write the time the diaper was
collected in the box below.
Is this a First Morning Void?
Place that bag inside the larger bag
labeled Diaper Urine. Store the bag in
the cooler until it is collected by the
field team.
□YES
Time:
Page 19 of 42
□NO
AM / PM
Day 3
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Page 20 of 42
Day 3
Activity Monitors
1
2
Place the belt with the activity monitor
on your child’s waist. Make sure the
arrow on the monitor is pointing up
toward their head.
Remove the charging plug from the
QSTARZ travel recorder.
3
Please keep the QSTARZ travel
recorder on your child all day. If that is
not possible, place it on something
that is always near your child (for
example a stroller, diaper bag,
backpack).
Write what time it is now in the box
below.
Start Time:
Time
AM / PM
Page 21 of 42
Reason
Day 3
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Page 22 of 42
Day 3
Stool Sample (Toilet Trained)
1
2
With your child’s help, determine
when a bowel movement is imminent.
If possible, have the child urinate first.
Note: If the stool sample cannot be
collected on this day, it can be
collected any day before the field
team returns.
Lift the lid and seat on the toilet and
pull 2 feet or so of plastic wrap from
the roll. Place the loose plastic wrap
on the floor and hold with your foot as
you loosely cover the toilet bowl,
leaving a hand-width opening at the
front for toilet paper disposal.
4
3
Leave plenty of plastic wrap on the
sides of the bowl to make collection
easier.
Page 23 of 42
Lower the seat onto the plastic
wrap to hold it in place and have
your child use the toilet.
Day 3
Stool Sample (Toilet Trained - continued)
5
6
Ensure that soiled toilet paper is
disposed of into the toilet through the
opening in front of the plastic. If
possible, any urine in the plastic wrap
should be disposed of through the
opening either now or in step 8.
Put on a pair of purple gloves from
your sample kit.
8
7
Open the sample collection jar
labelled Stool Sample.
Carefully lift the plastic wrap using the
extra amount from the outside of the
bowl and loosely wrap the stool
sample as if you are forming a bag.
Page 24 of 42
Day 3
Stool Sample (Toilet Trained - continued)
9
10
Place the plastic wrapped stool
sample inside the collection jar.
Close the lid on the sample jar. If the
outside of the jar or lid is soiled, use
toilet paper to remove any stool
material. Place the sample jar inside
the labeled zip-lock bag and seal.
Place that bag inside another zip-lock
bag and seal.
11
12
Is this the first bowel movement after the
duplicate diet collection?
Yes
No
If known, please record the date and
time of your child’s last bowel
movement in the box below.
Date:
Time:
Remove the gloves and dispose of
them with household trash. Place the
bag containing the stool sample jar
in the cooler until the sample is
collected by the field team.
AM / PM
Please record the date and time of the
stool sample collection in the box
below.
Date:
Time:
Page 25 of 42
AM / PM
Day 3
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Page 26 of 42
Day 3
Stool Sample (Diaper Collection)
1
2
When a diaper is found to be dirty
(contain stool), retrieve the stool
sample collection packet which
contains two zip-lock bags.
Remove the diaper as usual. Fold the
diaper in half to cover the contents.
Set aside until a new diaper is in place
and the child is returned to a safe
location and activities. Do not place
any baby wipes inside the soiled
diaper.
3
4
Place the diaper in the small labeled
zip-lock bag and seal. Place the
small zip-lock bag inside the larger
zip-lock bag and seal.
Place the bag containing the stool
sample in the cooler until the sample
is collected by the field team.
Page 27 of 42
Day 3
Stool Sample (Diaper Collection - continued)
5
Is this the first bowel movement after the
duplicate diet collection?
Yes
No
If known, please record the date and
time of your child’s last bowel
movement in the box below.
Date:
Time:
AM / PM
Please record the date and time of the
stool sample collection in the box
below.
Date:
Time:
AM / PM
Page 28 of 42
Day 3
End of the Day
1
2
At the end of the day, please remove
the belt with the activity monitor from
your child.
Time:
Please re-connect the QSTARZ travel
recorder to the plugged-in charger.
AM / PM
3
4
REMINDER!
Collect first morning
void Urine Sample
Place the reminder note on the toilet
or other prominent location. Write the
time of the last void before the
morning void is collected tomorrow in
the box below.
If your child is not toilet trained,
please put one of the diapers from the
sample kit on your child before he or
she goes to bed. Record the time of
the last wet diaper in the box below.
Time:
Time:
AM / PM
Page 29 of 42
AM / PM
Day 3
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Page
Page 30 of 42
Day 4
Day 4 Checklist
Use this checklist to mark the completed activities for Day 4
Silicone Band Kept on Child
Urine Collection Completed and Stored
Activity Monitors Placed for the Day and Removed Prior to Sleep
Page 31 of 42
Day 4
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Page
Page 32 of 42
Day 4
Silicone Band
1
2
If the band has to be removed or
placed on a different location (wrist to
ankle, etc.), write what was done
below.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Please leave the silicone band on your
child until the field team returns.
__________________________________________________________
__________________________________________________________
Page 33 of 42
Day 4
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Page
Page 34 of 42
Day 4
Urine Collection (Toilet Trained First Morning Void)
1
2
Have your child rinse his or her hands
with water and air or towel dry them.
Put on a pair of purple gloves from
your sample kit.
4
3
When your child is ready to urinate,
remove the cap from the Day 4 Urine
collection container and place the cap
with the inside up in a safe place
where it is unlikely to be knocked
over. Do not touch the inside of the
container or cap at any time.
Have your child urinate into the
collection container. Collect the entire
amount of urine and assist as
necessary.
Is this a First Morning Void?
Page 35 of 42
□YES
□NO
Day 4
Urine Collection (Toilet Trained First Morning Void - continued)
5
6
Recap the collection container. If the
container is wet, wipe it down with
toilet paper or a paper towel.
Place the collection container in the
zip-lock bag with absorbent material.
Remove excess air from the bag and
seal it.
7
8
Remove the gloves and throw them
away. Write the time the sample was
collected in the box below.
Time:
AM / PM
Place the bag containing the sample in
the cooler as soon as possible after
sample collection.
Page 36 of 42
Day 4
Diaper Urine Collection
1
2
Collect the first wet diaper of the
morning. If the diaper is dirty
(contains stool), and a stool sample
was not collected on Day 3, use that
as the stool sample and place a clean
diaper on your child and collect the
next wet diaper.
Put the diaper inside of the zip-lock
bag labeled Diaper Urine Day 4 and
seal the bag.
4
3
Please write the time the diaper was
collected in the box below.
Is this a First Morning Void?
Place that bag inside the larger bag
labeled Diaper Urine. Store the bag
in the cooler until it is collected by
the field team.
□YES
Time:
Page 37 of 42
□NO
AM / PM
Day 4
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Page 38 of 42
Day 4
Activity Monitors
1
2
Place the belt with the activity monitor
on your child’s waist. Make sure the
arrow on the monitor is pointing up
toward their head.
Remove the charging plug from the
QSTARZ travel recorder.
3
Please keep the QSTARZ travel
recorder on your child all day. If that is
not possible, place it on something
that is always near your child (for
example a stroller, diaper bag,
backpack).
Write what time it is now in the box
below.
Start Time:
Time
AM / PM
Page 39 of 42
Reason
Day 4
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Page
Page 40 of 42
Day 4
End of the Day
1
2
At the end of the day, remove the belt
with the activity monitor from your
child. Record the time it is now in the
box below.
Please re-connect the QSTARZ travel
recorder to the plugged-in charger.
End Time:
AM / PM
Page 41 of 42
Day 4
.
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Page
Page 42 of 42
| File Type | application/pdf |
| Author | Clifton, Matthew |
| File Modified | 2015-10-30 |
| File Created | 2015-10-28 |