0920-1011 Severe Pulmonary Disease Associatd with E-Cigarette Use

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 1

SEVERE PULMONARY DISEASE ASSOCIATED
WITH E-CIGARETTE USE OUTBREAK
CASE INTERVIEW SHORT FORM (CDC)

August 27, 2019

Page 1 of 16

Public reporting burden of this collection of information is estimated to average 60 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 2

Contents
Interview Form ...........................................................................................................................................................3
INTERVIEW DETAILS ...............................................................................................................................................3
TRACKING ...............................................................................................................................................................3
INTERVIEW ATTEMPT INFORMATION ...................................................................................................................3
PATIENT DEMOGRAPHICS .....................................................................................................................................3
ILLNESS HISTORY ....................................................................................................................................................4
JOB/SCHOOL ..........................................................................................................................................................5
VAPING PRODUCTS ................................................................................................................................................5
CHANGES IN VAPING BEHAVIORS ...................................................................................................................... 11
GENERAL SUBSTANCE USE.................................................................................................................................. 14
OTHER EXPOSURES ............................................................................................................................................. 15
OTHER MEDICATIONS/SUPPLEMENTS ............................................................................................................... 15
***END INTERVIEW HERE*** ............................................................................................................................. 16

Page 2 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 3

Interview Form
INTERVIEW DETAILS
[TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
o
o

Patient or proxy (parent/guardian) interview?

Yes
No

TRACKING
[TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
CDC CASE ID (deidentified)
INTERVIEW ATTEMPT INFORMATION
[TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
Patient refused interview or was lost to follow-up

o
o

Yes
No

***BEGIN INTERVIEW HERE***
Suggested script: Please read the following script if you are able to reach the patient or a proxy for an
interview:
I'm calling from the [jurisdiction] Health Department. I'm calling because you might be part of a group of
people who have gotten sick after vaping.
Vaping includes the use of electronic devices that can vaporize a combination of nicotine, flavors, and/or
other substances (e.g. marijuana, THC, THC concentrates, CBD, synthetic cannabinoids) for inhalation.
Examples of these devices include electronic cigarettes or e-cigarettes, such as JUUL, SMOK, Suorin, Vuse, or
blu. You also may know them as vapes, mods, e-cigs, e-hookahs, vape-pens, or some other electronic vapor
product.
Most people who have gotten sick have been hospitalized overnight with several ending up in the intensive
care unit. We are working with hospitals, doctors and other health departments to try to understand what is
causing this illness so that we can keep other people from getting sick. We heard about your illness from your
health care provider. We would like to learn more about your symptoms and to understand if something you
vaped might have made you sick. Do you have a few minutes to share your experience with this illness?
Your responses will help us better understand what may be causing illness.
PATIENT DEMOGRAPHICS
o Male
Sex
o Female
o Hispanic or Latino
How do you describe your ethnicity?
o Not Hispanic or Latino
How do you describe your race? (select all that apply)
Page 3 of 16

o
o
o

White
Black or African American
American Indian or Alaska Native

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 4
o
o

Asian
Native Hawaiian or Other Pacific
Islander

Shortness of breath

o
o
o

Yes
No
Unknown

Chest pain

o
o
o

Yes
No
Unknown

Pain on breathing in

o
o
o

Yes
No
Unknown

Fever

o
o
o

Yes
No
Unknown

Cough

o
o
o

Yes
No
Unknown

Headache

o
o
o

Yes
No
Unknown

Nausea

o
o
o

Yes
No
Unknown

Vomiting

o
o
o

Yes
No
Unknown

Diarrhea or loose stools

o
o
o

Yes
No
Unknown

Abdominal pain

o
o

Yes
No

Age (in years)
ILLNESS HISTORY
When did symptoms start (when did you first begin to feel ill)?
Date: (DD/MM/YYYY)
Time: (HH:MM AM/PM) if available
What symptoms have you experienced since first becoming ill
(select all that apply)?

Page 4 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 5

Other symptoms (open-ended)?

o

Unknown

o
o
o

Yes
No
Unknown

o
o

Yes
No

o
o

Yes
No

[IF YES] Please list other symptom(s)
Which symptom began first?
Do you have any thoughts about why you may have become
ill?
Do you have any underlying medical conditions [prompt:
asthma, COPD or other lung condition, heart disease]?
[IF YES] Please list
JOB/SCHOOL
Do you have a job?
[IF YES] What is your occupation or job function?
Have you ever worked in a job in which you were regularly
exposed to any of the following: coal, beryllium, silica,
asbestos, or pesticides?
[IF YES] Specify
VAPING PRODUCTS

_____________
o Yes
o No
o Unsure
_____________

The next several questions are about vaping or e-cigarette use, such as JUUL, SMOK, Suorin, Vuse, or blu. You
also may know them as vapes, vaporizers, mods, e-cigs, e-hookahs, dab pens, rigs, vape-pens, or electronic
nicotine delivery systems (ENDS).
Please consider the vaping of any substance (e.g., nicotine, marijuana, CBD, synthetic cannabinoids, flavors
or other substances).
[Repeat questions as necessary for each product/device or substance used in the past 3 months before
symptoms began.]
Did you vape or use e-cigarettes in the past 3 months before symptoms began [Y/N]?
IF YES:
What type of device(s) did you use within the past 3 months before symptoms started (select all that apply)?
• Disposable e-cigarette or vape [Y/N]
• E-cigarette or vape with pods or cartridges [Y/N]
• E-cigarette or vape with a tank that you refill with liquids (including mod or
modifiable systems) [Y/N]
• Vaporizer [Y/N]
• Sub-ohm devices [Y/N]
• Other (specify): _________
Page 5 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 6
•

Don’t know

What substances did you use within the past 3 months before symptoms started (select all that
apply)?
• nicotine [Y/N]
o [IF YES] Strength? _____________
o [IF YES] free-base nicotine? [Y/N]
o [IF YES] nicotine salts? [Y/N]
• Marijuana, THC, THC concentrates, hash oil, wax [Y/N]
• Dank vapes [Y/N]
• Synthetic cannabinoids (e.g., K2 or Spice) [Y/N]
• CBD or CBD oil [Y/N]
• flavors [Y/N]
• something else (specify): ________]
• Don’t know
For each substance that you used in the 3 months before symptoms started, when was the date of last use
before symptoms started?
Date of last use
(MM/DD/YYYY)
Nicotine (free-base or nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC concentrates (e.g.,
dabs, dab wax, dab cards), hash oil, wax
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Flavors
Check if not used: [ ]
Something else
Check if not used: [ ]
What brand(s) did you use within the past 3 months before symptoms started? Be as specific as
possible for each product currently used. _________________
What flavor(s) did you use within the past 3 months before symptoms started? Be as specific as
possible for each product currently used. __________________
Have you dabbed within the past 3 months before symptom onset? [Y/N]
Page 6 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 7
[IF YES for dabbing] What do you dab?: ___________
[IF YES for dabbing] How do you dab?: ___________
Did you use pre-filled cartridges or pods of vaping liquid within the past 3 months before symptoms started?
[Y/N]
[IF YES]: Describe pre-filled cartridge (Brand, Type):_______
[IF YES]: What substance(s) are contained in these pre-filled cartridges or pods?
• nicotine [Y/N]
o [IF YES] free-base nicotine? [Y/N]
o [IF YES] nicotine salts? [Y/N]
• Marijuana, THC, THC concentrates, hash oil, wax [Y/N]
• Dank vapes [Y/N]
• Synthetic cannabinoids (e.g., K2 or Spice) [Y/N]
• CBD or CBD oil [Y/N]
• flavors [Y/N]
• something else (specify): ________
[IF YES]: Have you ever added any substance to a prefilled cartridge? [Y/N]
[IF YES]: What have you added to your cartridge?: _______
In the 3 months before symptoms started, did you ever hacked or modified your vaping device or liquid
cartridge in any way [Y/N]?
[IF YES] Please describe: _________
In the 3 months before symptoms started did you buy e-juice, e-liquid or vaping liquid to put in your device
[Y/N]?
[IF YES]: What e-liquid or liquid do you use (include brand, substance used):
__________________________________
In the 3 months before symptoms started, did you make or mix your own e-liquid, e-juice, or vaping liquid
[Y/N]?
[IF YES]: What ingredients did you use?: __________
For each substance that you vaped in the 3 months before symptoms started, how frequently did you use
this substance?
Never Monthly 2-4
2-3 times
4-6 times per
Daily
or less
times
per week
week
per
month
Nicotine (free-base or
nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC
concentrates (e.g.,
dabs, dab wax, dab
cards), hash oil, wax
Page 7 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 8
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Synthetic
cannabinoids (e.g., K2
or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Flavors
Check if not used: [ ]
Something else (if so,
specify): ________
Check if not used: [ ]
Please answer the following for each substance that you used in the 3 months before symptoms started.
How did you get or buy this product or substance? Please specify:
Substance

Nicotine (free-base or
nicotine salts)
Check if not used: [ ]

Marijuana, THC, THC
concentrates (e.g.,
dabs, dab wax, dab
cards), hash oil, wax
Check if not used: [ ]

Where purchased or obtained (please select all
that apply)
Specify details including: location, person,
actual item purchased or obtained, etc.
• Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
• Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
• Bought it at a pop-up shop
[IF YES] specify details: ___________
• Bought it from another person
[IF YES] specify details: ___________
• Bought it online
[IF YES] specify details: ___________
• It was given to me by another person
[IF YES] specify details: ___________
• Other (specify details):
______________________
• Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
• Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
• Bought it at a pop-up shop
[IF YES] specify details: ___________
Page 8 of 16

Date of last purchase prior to
symptom onset?
(MM/DD/YYYY)

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 9
•
•
•
•
Dank vapes
Check if not used: [ ]

•
•

•
•
•
•
•

Synthetic cannabinoids
(e.g., K2 or Spice)
Check if not used: [ ]

•
•

•
•
•
•
•

CBD or CBD oil
Check if not used: [ ]

•

Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Other (specify details):
______________________
Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
Bought it at a pop-up shop
[IF YES] specify details: ___________
Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Other (specify details):
______________________
Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
Bought it at a pop-up shop
[IF YES] specify details: ___________
Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Other (specify details):
______________________
Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
Page 9 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 10
•

•
•
•
•
•

Flavors
Check if not used: [ ]

•
•

•
•
•
•
•

Something else (please
specify if relevant):
_______
Check if not used: [ ]

•
•

•
•
•
•

Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
Bought it at a pop-up shop
[IF YES] specify details: ___________
Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Other (specify details):
______________________
Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
Bought it at a pop-up shop
[IF YES] specify details: ___________
Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Other (specify details):
______________________
Bought it at a vape shop or dispensary
[IF YES] specify details: ___________
Bought it at a different type of store
(such as a convenience store, gas
station, supermarket)
[IF YES] specify details: ___________
Bought it at a pop-up shop
[IF YES] specify details: ___________
Bought it from another person
[IF YES] specify details: ___________
Bought it online
[IF YES] specify details: ___________
It was given to me by another person
[IF YES] specify details: ___________
Page 10 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 11
•

Other (specify details):
______________________

Subsection: modifiable devices (“Mods”):
Now I am going to ask you about each of the vaping or e-cigarette devices you used and how you used them in
the 3 months before symptoms started.
[Repeat as necessary for each mod device used in the past 3 months before symptoms began.]
Is the device modifiable ("mods")? [Y/N]
E.G.: A device where you can modify voltage; whether
the user is adding additional equipment such as an
atomizer for "dripping;" and/or if the user is
tampering with the device to change settings (e.g.
exposing heating coils to "drip" liquids directly on the
heating device and get a bigger cloud of aerosol, etc.)
IF YES:
What brand/type of coils did you use? _________
What brand/type of atomizer did you use? ____________
Did you notice a build-up on the coil when using it?
____________
What brand/type of wicks did you use? ____________
In the past 3 months before symptoms started, have you
cleaned your mod device? [Y/N]
[IF YES] what do you use to clean your mod device?
____
Do you use for device for dripping? [Y/N]
CHANGES IN VAPING BEHAVIORS
In the last 3 months before symptoms started, did you change where you purchased or got your product(s)?
Please answer for each product used.
Changes in purchase?
If yes, what were the
[Y/N]
changes? (specify)
Device Used (overall)
e-liquid, e-juice, or liquid product used (overall)
Check if not used: [ ]
Nicotine (free-base or nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC concentrates (e.g., dabs,
dab wax, dab cards), hash oil, wax
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Page 11 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 12
Flavors (list and complete for all): _______
___________________
Check if not used: [ ]
Something else (specify if relevant): _____
Check if not used: [ ]
In the last 3 months before symptoms started, did you change the e-liquid, e-juice, liquid product, or device
that you used? Please answer for each device or substance used.
Device/Substance

Changes in type used?
[Y/N]

Device Used (overall)

If yes, what were the
changes? (specify)

e-liquid, e-juice, or liquid product used (overall)
Check if not used: [ ]
Nicotine (free-base or nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC concentrates (e.g., dabs,
dab wax, dab cards), hash oil, wax
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Flavors (list and complete for all): _______
___________________
Check if not used: [ ]
Something else (specify if relevant): ____
Check if not used: [ ]
In the last 3 months before symptoms started, did you notice any changes in taste, texture, smell, clarity, or
quality of the product(s)? Please answer for each substance used.
Substance
Notice changes in taste,
If Yes: describe the
texture, smell, clarity, or change(s)?
quality of the product
[Y/N]?
Nicotine (free-base or nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC concentrates (e.g., dabs,
dab wax, dab cards), hash oil, wax
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Page 12 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 13
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Flavors (list and complete for all): _______
___________________
Check if not used: [ ]
Something else (specify if relevant): _______
Check if not used: [ ]

In the last 3 months before symptoms started, did you notice any changes in how you feel after using the
product e.g., cough, trouble breathing, dizziness, confusion, the buzz or high from use, or any other physical
changes in symptoms or experiences)? Please answer for each product used.
Changes in how you feel If yes, what were the
after using? [Y/N]
changes? (specify)
Device Used (overall)
e-liquid, e-juice, or liquid product used (overall)
Check if not used: [ ]
Nicotine (free-base or nicotine salts)
Check if not used: [ ]
Marijuana, THC, THC concentrates (e.g., dabs,
dab wax, dab cards), hash oil, wax
Check if not used: [ ]
Dank vapes
Check if not used: [ ]
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
CBD or CBD oil
Check if not used: [ ]
Flavors
Check if not used: [ ]
Something else (if so, specify): _____
Check if not used: [ ]
PRODUCT TESTING SECTION (ELECTRONIC PRODUCTS ONLY):
Do you have any device(s), substance(s), product(s), or
product packaging left for any of the substances or products
you used in the last 90 days (3 months)?
[IF YES] Can public health get it for testing?
Did you share your product(s) with anyone (e.g., friends,
family) in the 3 months before symptoms started?
Page 13 of 16

o
o
o
o
o
o
o

Yes
No
Unknown
Yes
No
Yes
No

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 14

[IF YES] Did that person(s) develop similar
illness?

o

Unknown

o
o
o

Yes
No
Unknown

GENERAL SUBSTANCE USE

Cigarettes
Cigars (regular cigars, little cigars,
cigarillos)
o
Hookah/Waterpipe
o
Pipe tobacco
o
Roll-your-own
o
Bidis
o
Heated tobacco products
Have you inhaled any of the following substances in the past 3
o
Non-vaped Cannabinoids (e.g.,
months (90 days) before symptoms started?
marijuana, hash, synthetic
cannabinoids (K2 or Spice))
o
Heroin
o
Cocaine
o
Methamphetamine
o
Huffing (e.g., paint, glue, bath salts)
o
Something else ______
Non-vaped Cannabinoids (e.g., marijuana, hash, synthetic cannabinoids (K2 or Spice) Details:
o
o

IF YES TO USE IN PAST 3 MONTHS BEFORE SYMPTOMS STARTED:
Approx. date last used (MM/DD/YYYY)
What type of cannabinoids did you use (select all that apply)?
• Marijuana, hash [Y/N]
• Synthetic cannabinoids (e.g., K2 or Spice) [Y/N]
• Dabbed marijuana (e.g., oils or waxes) [Y/N]
• Dabbed CBD concentrate [Y/N]
What brand(s) did you use (within the past 3 months before symptoms started)?: ______
For each substance that you smoked or dabbed, how frequently did you use this substance in the 3 months
before symptoms started?
Non-daily
Daily

Marijuana, hash
Check if not used: [ ]
Synthetic cannabinoids (e.g., K2 or Spice)
Check if not used: [ ]
Dabbed marijuana (e.g., oils or waxes)
Check if not used: [ ]
Page 14 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 15
Dabbed CBD concentrate
Check if not used: [ ]

OTHER EXPOSURES
For the last 6 months before symptoms started, have you
been exposed to any of the following?
Moldy hay, grain, cheese, or wood bark?

o
o
o

Yes
No
Unknown

Animal droppings or urine?

o
o
o

Yes
No
Unknown

o Yes
Birds in your home, as part of a hobby, or at work?
o No
o Unknown
o Yes
Humidifiers, hot tubs, or saunas?
o No
o Unknown
o Yes
Soil or compost (e.g., frequent handling of soil)?
o No
o Unknown
o Yes
Spray paints or polyurethane foam?
o No
o Unknown
o Yes
Did you spend time in an infrequently used space or
o No
structure (e.g., attic, cabin)?
o Unknown
o Yes
Did you inhale chemicals or toxins (e.g., cleaning products,
o No
occupational exposures)?
o Unknown
OTHER MEDICATIONS/SUPPLEMENTS (ask about frequency of being taken in the last three months)
Over the counter medications [list all]
Prescription medications [list all] (clarify if they took any
prescription medications that were not prescribed to them).
Include route of administration (oral, inhaled, topical, etc.)
Did you take any prescription medications that were not
o Yes
prescribed to you?
o No
[IF YES] Which?
Vitamins and supplements, including things that you’ve
purchased online [list all]
OTHER NOTES (include details of any conversation with parent
or guardian)
Page 15 of 16

CDC Case Questionnaire for E-cigarette Investigation SHORT FORM
August 27, 2019
Page 16

***END INTERVIEW HERE***

Page 16 of 16

Form Approved
OMB # 0920-1011
Exp. 01/31/2020
CDC Specimen Manifest Form for E-cigarette Investigation
August 27, 2019
Page 1

SEVERE PULMONARY DISEASE ASSOCIATED WITH ECIGARETTE USE OUTBREAK
SPECIMEN MANIFEST FORM (CDC)
August 27, 2019

CDC estimates the average public reporting burden for this collection of information as 10 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 (0920-1011).

CDC Specimen Manifest Form for E-cigarette Investigation
August 27, 2019
Page 2

Specimen Manifest Form
CDC Case
ID

State Case
ID

Sample
ID

Matrix
(specimen
type)

Shipping
Box # or ID

Position in
Shipping
Box

Volume
(mL) of
Specimen

Collection
Date of
Specimen

Comments about Specimen