Form 0923-0056 Clinic Visit Checklist and Body Measurements - Burmese I

SPID #: ________________

Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

Attachment 8b. Clinic visit checklist and body measurements, Burmese Immigrants and their Descendants

Milwaukee Angler Project

Burmese Immigrants and their Descendants Checklist

1. Screen for eligibility

   1. If eligible,

Complete contact information form

Provide consent form to review while waiting for interview

Provide laminated copy of questionnaire to review while waiting

2. If ineligible,

Provide individual bus pass or reimburse for parking

2. Consent Form

Ask if participant had an opportunity to read it.

Review key points

Ask if there are any questions

Have participant sign two copies. One copy for participant and one for file.

3. Collect hair sample (only if participant consents to it)

Put SPID label on Ziploc baggie

Follow all of the CDC guidelines

Seal Ziploc baggie once hair sample is in it

Double bag Ziploc baggie with hair sample in it

4. Take physical measurements

Height #1______________in #2_______________in #3____________ in

Weight #1______________lbs

Waist size #1______________in #2_______________in #3_____________in

Blood pressure #1____________ #2_______________ #3_____________

(Continued on next page)

ATSDR estimates the average public reporting burden for this collection of information as 35 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0923-17IY).

5. Collect blood sample Blood Draw Time ______________

Phlebotomist asks questions and evaluates pallor to determine ability/safety for blood sample collection (”Do you feel faint currently?;” ”How are you feeling right now?;” “When is the last time you ate?”)

Phlebotomist asks question to determine preference of arm used for blood sample collection (“Which arm would you prefer to have the blood drawn”), subject to any medical considerations (Mastectomy/related; Shunt, fistula or graft; Obesity; Hematoma; Recent IV; Skin sores; Burns, scars, tattoos; Cast; Damaged veins; Edema)

6. Obtain urine sample

Time urine sample collected _______________

7. Questionnaire Administration

Administer questionnaire using REDCap

Answer any questions

SHOW or DHS staff enter responses in English into REDCap

8. Next steps

Discuss what will happen next and the timeline

9. Incentive

$20 gift card for providing blood and urine samples

$20 gift card for completing questionnaire

$20 gift card for completion of all project components

10. Instruct on how to use referral coupons

11. Provide three referral coupons

12. Complete Redcap sections:

Visit

Post Processing

# of purple top tubes (for CDC) _______

# of amber bottles (for CDC) _______

# of Urine bottles (for CDC) ________

NOTES:

Visit Conducted By: ­­­­­­­­­­­­______________________________________________________________ Date: ­­­­­­­______________________

Burmese Participants Checklist Page 4