1 Survey

Appendix A A.2.3.k–3

For Office Use Only

Participant # __ __ __ __ __

Visit #__ __ __ __ __

National Children’s Study

Breast Milk Data Collection Form

As part of the National Children’s Study, we are asking you to provide a breast milk sample.

You have been provided materials for collecting breast milk, including breast pump accessories (breast shields, tubing, valves, membranes, and collection bottles), a pre-labeled plastic conical tube, and a pre-labeled brown glass bottle.

Questions for Breast Milk Collection	Response
1) What is today’s date?	___ ___ /___ ___ / ___ ___ ___ ___
2) What time did you last pump or nurse before collecting your breast milk sample?	___ ___ : ___ ___ □ am □ pm
3) What time did you pump your breast milk sample?	___ ___ : ___ ___ □ am □ pm
4) What time did you place the samples in the freezer?	___ ___ : ___ ___ □ am □ pm
5) Comments/Notes:	_______________________________________ _______________________________________
Please be sure to include this form when shipping the sample to the repository. Thank you for providing this information!
For Repository Use only
Date received: ___ ___/ ___ ___/ ___ ___ ___ __		Condition: □ Frozen □ Thawed
Conical tube volume: ____________ml		Brown glass bottle volume: ________ml

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