Clicnic/Home Visit - Developmental Assessment (Mother)

The Study to Explore Early Development (SEED) - Phase 3 (Modified for COVID-19 Impact Assessment)

Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17

Clicnic/Home Visit - Developmental Assessment (Mother)

OMB: 0920-1171

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S tudy to Explore Early Development



Interviewer_______________ Study ID#_____________

Date of Completion ___________

Time of Completion___________


Blood Draw Information Form


1. Please tell me all vaccinations, medications, vitamins, and supplements, both prescription and over the counter, <you have> taken in the last month.

[Interviewer: Check box for MOST RECENT time frame when medication was last taken.]


If no medications, vitamins, or supplements given in last month, check here: ____


Type of substance Last 7 days Last month

1)_________________________ □ □

2) _________________________ □ □

3)_________________________ □ □

4) _________________________ □ □

5) _________________________ □ □

6) _________________________ □ □

7) _________________________ □ □

8) _________________________ □ □


2. List any cold, flu, fever, or other illness <you have> had in the last 2 weeks. [Interviewer: Check box for MOST RECENT time frame when illness occurred.]



If no illness in last 2 weeks, check here: _______

Illness Last 2 days Last 2 weeks

1) _________________________ □ □

2) _________________________ □ □

3) _________________________ □ □

4) _________________________ □ □


3. Have you or anyone else smoked cigarettes, cigars, No

or pipes anywhere inside your home in the past week? Yes, person giving blood smoked

Yes, someone else in home smoked

Version 9-2015


File Typeapplication/msword
File TitleStudy Start Blood Draw form 2007
AuthorBusiness Center One
Last Modified ByJohnson-James, Treana (CDC/ONDIEH/NCBDDD) (CTR)
File Modified2016-09-15
File Created2016-09-01

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