0920-1173 Food Log

Attachment E

Food Log

Form Approved

OMB No. 0920-1173

Exp. Date 03/31/2020

• Attached is the log you will be using to track certain foods you eat and beverages you drink for the three (3) days before you collect your urine specimen.

• Investigation staff will use this information to see whether and how the foods you eat and beverages you drink affect your urine test results.

Directions

• Please write the date in the date box at the top each of the pages.

• Complete the Food Log as described on the pages.

• Do not eat any fish or shellfish during the three (3) days before you collect your urine specimen. If you accidentally forget and eat some, please record it on your checklist. Fish and shellfish are potential sources of dietary exposure to arsenic. Consuming these products during this investigation may make it difficult to assess exposure to arsenic from drinking water.

• After the Food Log has been completed, place it in the plastic bag provided to you and seal the bag.

• Collect your urine specimen on the morning of Day 4.

• Return the Food Log to investigation staff with your well water and urine specimens.

Remember:

• Do not eat any fish or shellfish during the three (3) days before you collect your urine specimen. If you accidentally forget and eat some, please record it on your checklist.

• Collect your urine on the morning of Day 4.

But wait! I have questions!

Please contact <CDC contact> with questions.

CDC estimates the average public reporting burden for this collection of information as 5 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 (0920-1173).

Day 1: __________________(enter date)

Check the box if you ate any of that food today. Write approximately how many ounces you ate next to it (the total amount for all meals/snacks during the day). For example, 1/2c = 4oz; 1c = 8oz; a portion the size of deck of cards = 3oz; 1 tablespoon = 0.5oz.

☐ White rice ____________ oz

☐ Brown rice ____________ oz

☐ Rice crackers ____________ (# crackers)

☐ Rice cakes ____________ (# cakes)

☐ Rice bread ____________ (# slices)

☐ Rice noodles ____________ oz

☐ Rice wine vinegar ____________ oz

☐ Mushrooms ____________ oz

☐ Canned/packaged tuna fish ____________ oz

☐ Freshwater or marine fish ____________ oz

☐ Shellfish ____________ oz

☐ Smelts ____________ oz

☐ Seaweed ____________ oz

☐ Nuts/seeds ____________ oz

☐ Potatoes (any type except sweet potatoes) ____________ oz

☐ Sweet potatoes ____________ oz

☐ Parsnips ____________ oz

☐ Turnips ____________ oz

☐ Products with brown rice derivatives (like brown rice syrup which is an ingredient in some granola bars, energy bars, and energy gels)

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount)

Check the box if you drank that beverage today. Write approximately how many ounces you drank next to it (the total amount for all meals/snacks during the day). For example. 4oz = 1/2c; 8oz = 1c.

☐ Tap water ____________ cups

☐ Bottled water ____________ cups

☐ Mineral water ____________ cups

☐ Rice milk ____________ cups

☐ Other rice beverages ______ cups

☐ Apple juice __________ cups

☐ Grape juice _________ cups

☐ Tea __________ cups

☐ Coffee __________cups

Day 2: __________________(enter date)

Check the box if you ate any of that food today. Write approximately how many ounces you ate next to it (the total amount for all meals/snacks during the day). For example, 1/2c = 4oz; 1c = 8oz; a portion the size of deck of cards = 3oz; 1 tablespoon = 0.5oz.

☐ White rice ____________ oz

☐ Brown rice ____________ oz

☐ Rice crackers ____________ (# crackers)

☐ Rice cakes ____________ (# cakes)

☐ Rice bread ____________ (# slices)

☐ Rice noodles ____________ oz

☐ Rice wine vinegar ____________ oz

☐ Mushrooms ____________ oz

☐ Canned/packaged tuna fish ____________ oz

☐ Freshwater or marine fish ____________ oz

☐ Shellfish ____________ oz

☐ Smelts ____________ oz

☐ Seaweed ____________ oz

☐ Nuts/seeds ____________ oz

☐ Potatoes (any type except sweet potatoes) ____________ oz

☐ Sweet potatoes ____________ oz

☐ Parsnips ____________ oz

☐ Turnips ____________ oz

☐ Products with brown rice derivatives (like brown rice syrup which is an ingredient in some granola bars, energy bars, and energy gels)

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount)

Check the box if you drank that beverage today. Write approximately how many ounces you drank next to it (the total amount for all meals/snacks during the day). For example. 4oz = 1/2c; 8oz = 1c.

☐ Tap water ____________ cups

☐ Bottled water ____________ cups

☐ Mineral water ____________ cups

☐ Rice milk ____________ cups

☐ Other rice beverages ______ cups

☐ Apple juice __________ cups

☐ Grape juice _________ cups

☐ Tea __________ cups

☐ Coffee __________cups

Day 3: __________________(enter date)

Check the box if you ate any of that food today. Write approximately how many ounces you ate next to it (the total amount for all meals/snacks during the day). For example, 1/2c = 4oz; 1c = 8oz; a portion the size of deck of cards = 3oz; 1 tablespoon = 0.5oz.

☐ White rice ____________ oz

☐ Brown rice ____________ oz

☐ Rice crackers ____________ (# crackers)

☐ Rice cakes ____________ (# cakes)

☐ Rice bread ____________ (# slices)

☐ Rice noodles ____________ oz

☐ Rice wine vinegar ____________ oz

☐ Mushrooms ____________ oz

☐ Canned/packaged tuna fish ____________ oz

☐ Freshwater or marine fish ____________ oz

☐ Shellfish ____________ oz

☐ Smelts ____________ oz

☐ Seaweed ____________ oz

☐ Nuts/seeds ____________ oz

☐ Potatoes (any type except sweet potatoes) ____________ oz

☐ Sweet potatoes ____________ oz

☐ Parsnips ____________ oz

☐ Turnips ____________ oz

☐ Products with brown rice derivatives (like brown rice syrup which is an ingredient in some granola bars, energy bars, and energy gels)

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount),

_____________________________________ (food & amount)

Check the box if you drank that beverage today. Write approximately how many ounces you drank next to it (the total amount for all meals/snacks during the day). For example. 4oz = 1/2c; 8oz = 1c.

☐ Tap water ____________ cups

☐ Bottled water ____________ cups

☐ Mineral water ____________ cups

☐ Rice milk ____________ cups

☐ Other rice beverages ______ cups

☐ Apple juice __________ cups

☐ Grape juice _________ cups

☐ Tea __________ cups

☐ Coffee __________cups

__________________________________ _____________

Signature Date