Clinic / Home Visit -Development Assessment (Child)

The Study to Explore Early Development (SEED) - Phase 3

Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17

Clinic / Home Visit -Development Assessment (Child)

OMB: 0920-1171

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Study to Explore Early Development

Saliva Sample Transmittal Form



Please complete this form while collecting your saliva sample. Use one form per person. See the instructions on the sheet titled “How to Collect Saliva Sample” for more information.



Saliva Collection (select one): OG-500 self-collection kit OG-575 assisted collection kit



Section A


Please answer these questions about the person giving these samples. Give both the date and time.


When did they last eat food?

___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM

M M D D Y Y (circle one)

When did they last brush their teeth?

___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM

M M D D Y Y (circle one)

When was the sample collected?

___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM

M M D D Y Y (circle one)


Section B


Tell us if you had any problems when collecting the sample.



Description of problems and other comments















Thank You!

Section E


To be completed by SEED Lab. Do not write in this box.


Date and Time of Receipt

___ ___ / ___ ___ / 20 ___ ___ ___ ___ : ___ ___ AM PM

M M D D Y Y (circle one)

Brush #

Received

Packaging

Consent Rec’d

Notes

Sample Quality

1

Yes

Satisfactory

Yes


Good Bad

2

Yes

Satisfactory

Yes


Good Bad

3

Yes

Satisfactory

Yes


Good Bad

Signature of Technician

Date


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File Modified0000-00-00
File Created0000-00-00

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