Form 0920-1170 Study Log Sheet

Form Approved

OMB No. 0920-1170

Expires 03/31/2019

STUDY NAME: LOG SHEET

Canine Leptospirosis Surveillance, Puerto Rico Clinic/Shelter Name: ________________________________________

Study ID (ex. A003)	Owner Last Name (write “N/A”, if shelter)	Dog's Name	Gender	Date Illness Onset (mm/dd/yy)	Lepto Rapid Test #1 (Date: m/dd/yy)	Lepto Rapid Test #2* (Date: m/dd/yy)	Specimens Collected for Shipment Select all that apply. (Date: m/dd/yy)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)
Place ID label here			☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Kidney Tissue ☐ Serum ☐ Kidney Culture ☐ Urine (cysto) ☐ Urine (free catch)

*Lepto Rapid Test #2: Perform test #2 if the first lepto rapid test was negative and blood was collected <7 days after symptom onset.

Gender: M = male MC = male, castrated

F = female FS = female, spayed

Page ______ of ______

Public reporting burden of this collection of information is estimated to average 1 minute 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1170).