EA participants biological testing tracking

Per- or Polyfluoroalkyl Substances Exposure Assessments (PFAS EAs)

PrtApndxB6_Biological Testing Tracking Form_20220609

OMB: 0923-0059

Document [docx]
Download: docx | pdf

Shape1

Form Approved

OMB No. 0923-0059

Exp. Date 06/30/2022

Appendix B6: Biological Testing Tracking Form



Shape2

ATSDR estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for moving from station to station at the data collection site and providing a blood and urine sample to the PFAS EA team. An agency may not conduct or sponsor, and a person is not required to respond to 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-0059).

PFAS EA Biological Testing Tracking Form



Shape3

Participant ID Number _______________________Sample Collection Date _______________________

PFAS EA Biological Testing Tracking Form:

Adult and Child Participants

  • Please indicate when you have completed the activity at each station

  • Make sure to bring your sheet of labels with you to each station

  • Return this form to the check-in area before you leave

  • Thank you for participating!



Station


Completion

Comments

Temperature below 100.4˚F/no self-reported symptoms

Yes

No


Sign In

Yes

No


Consent/Parental Permission/Assent Form

Yes

No


Appointment Made for Questionnaire

Yes

No


Blood Draw

Yes

No


Urine Sample Collection

Yes

No




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDavis, Stephanie I. (CDC/DDNID/NCEH/OD)
File Modified0000-00-00
File Created2023-08-28

© 2024 OMB.report | Privacy Policy