Clinic / Home Visit -Development Assessment (Child)

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