Clinic / Home Visit -Development Assessment (Child)

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

Attachment 17.a .Child Blood Draw Form SEED 3_tmj8-25-17

Clinic / Home Visit -Development Assessment (Child)

OMB: 0920-1171

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S tudy to Explore Early Development



Interviewer_______________ Study ID#_____________

Date of Completion ___________

Time of Completion___________


Blood Draw Information Form


1. Please tell me all vaccinations, medications, vitamins, and supplements, both prescription and over the counter, <child first name> has taken in the last month.

[Interviewer: Check box for MOST RECENT time frame when medication was last taken.]


If no medications, vitamins, or supplements given in last month, check here: ____


Type of substance Last 7 days Last month

1)_________________________ □ □

2) _________________________ □ □

3)_________________________ □ □

4) _________________________ □ □

5) _________________________ □ □

6) _________________________ □ □

7) _________________________ □ □

8) _________________________ □ □


2. List any cold, flu, fever, or other illness < child first name> has had in the last 2 weeks. [Interviewer: Check box for MOST RECENT time frame when illness occurred.]

If no illness in last 2 weeks, check here: _______

Illness Last 2 days Last 2 weeks

1) _________________________ □ □

2) _________________________ □ □

3) _________________________ □ □

4) _________________________ □ □



3. Have you or anyone else smoked cigarettes, cigars, No

or pipes anywhere inside your child’s home Yes, person giving blood smoked

in the past week?

Yes, someone else in home smoked

Version 9-2015



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