Form 0920-0888 Medical Testing

Attachment 6: Medical Testing Mock Form

Form Approved

OMB NO:

Exp. Date: xx/xx/20xx

This is a mock form that represents the medical testing that will take place during this study. The medical testing will include an oral temperature reading and the collection of two nasopharyngeal swabs and 5 ml of blood. Additionally, participants will be asked to don a mask and breathe and cough normally into a collection system for airborne particles for 40 minutes. The table below shows a detailed breakdown of the estimated time required for each step of the medical testing.

Step	Description	Time required (minutes)
Oral temperature measurement	Measure subject’s temperature with an oral thermometer	2
Nasopharyngeal mucus collection	Collect mucus from the back of both nasopharyngeal passageways using two extended nylon-flocked swabs	5
Preparation for aerosol collection	Explain procedure to subject, adjust seating and collection system position, fit mask to subject’s face and seal in place	5
Aerosol collection	Collect airborne particles from exhaled breath and coughs while subject sits with collection mask on and breathes and coughs normally.	40
Blood collection & monitoring period	Blood collection requires about 5 minutes. After blood collection, subject must be sit quietly and be monitored for 15 minutes for adverse reactions such as feeling dizzy or lightheaded, fainting, or excessive bleeding.	20
TOTAL		72

Public reporting burden of this collection of information is estimated at 72 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/Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333; Attn: PRA (XXXX).