Appointment Tracking Form

P_Att11_ApptTrackingForm_20180802.docx

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

Appointment Tracking Form

OMB: 0923-0061

Document [docx]
Download: docx | pdf

Attachment 11

Agency for Toxic Substances and Disease Registry

Pease Study

Study ID No.


|_________________|

Order Assigned by Coordinator

Comments

Completed

Clinic or

In-field

Date

mm/dd/yy

Time

hh:mm

0 clinic

1 home

Informed Consent

1.




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM

PM

0

1

Update Contact Information

2.




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Blood Draw/

Urine Collection

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Assess Current Medication

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Body Measurements

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Blood Pressure Measurements

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Questionnaire

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Neurobehavioral Battery

[__]




|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1

Received Gift Card

9.

TOTAL AMOUNT RECEIVED: [___] $25 [___] $50 [___] $75


SIGNATURE:



|__|__|/|__|__|/|__|__|

|__|__|:|__|__|

AM PM

0

1




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

© 2024 OMB.report | Privacy Policy