Clinical Test Report Tracking Form

P_Att22a_AdvncClinicalTestReportTrackingForm_20180802.docx

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

Clinical Test Report Tracking Form

OMB: 0923-0061

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Attachment 22a.

Pease Study

Advance Clinical Test Report Tracking Form


Study ID No. |_________________| (Adult/Parent)

Study ID No. |_________________| (Child)

Adult or Parent is the Target Person

Contact Information Label

NW = Non-working Number

NH = No One Home

TN = Target Person Not Home

TY = Target Person Home

CN = Call Not Scheduled

CS = Call Scheduled

CR = Call Rescheduled Scheduled (note date/time)

VC = Verbal Report Complete

VI = Verbal Report Incomplete

LR = Letter Report Mailed

O = Other (explain)

No.

DATE

mm/dd/yy

TIME

hh:mm

OUTCOME

CODE(S)

COMMENTS

INTERVIEWER

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-15

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