EA participants biological testing tracking

Form Approved

OMB No. 0923-0059

Exp. Date 06/30/2022

Appendix B6: Biological Testing Tracking Form

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

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