Supplemental documents

OMB control number 3041-0116

[INSERT COMPANY NAME]

DATA COLLECTION FORM FOR CIGARETTE LIGHTER CHILD TEST PANEL

C onducted for: Lighter:

Company Name Model Name / Number

all entries below this line must be made in black or blue ink by the tester whose name and signature appear below

Test Site:

Name Street Address City, State

Test Date: Tester Name: Tester Signature:

(mo/day/yr) Please Print

			Pair A			Pair B			Pair C
			LEFT	RIGHT		LEFT	RIGHT		LEFT	RIGHT
Child’s Full Name	First: Last:
Proper informed consent obtained?			YES ____ NO ____	YES ____ NO ____		YES ____ NO ____	YES ____ NO ____		YES ____ NO ____	YES ____ NO ____
Birth Date: (mo/day/yr)			| |	| |		| |	| |		| |	| |
Age (months):
Sex (M / F):
Surrogate Lighter #:
Surrogate lighter works?		Before: After:	YES ____ NO ____ YES ____ NO ____	YES ____ NO ____ YES ____ NO ____		YES ____ NO ____ YES ____ NO ____	YES ____ NO ____ YES ____ NO ____		YES ____ NO ____ YES ____ NO ____	YES ____ NO ____ YES ____ NO ____
Test Start Time:			: A.M. ____ P.M. ____			: A.M. ____ P.M. ____			: A.M. ____ P.M. ____
Operation: (001-600 sec. or None)
Tester Comments and Observed Method(s) of Operation / Attempted Operation (see codes):

Method of operation: 1 – Used one hand, thumb 2 – Used one hand, index finger 3 – Used two hands, thumb 4 – Used two hands, index finger 5 – Other (specify in tester comments field)

Data collection in accordance with 16 C.F.R. Part 1210.4(g)