Form A.2.3.L5 Survey

Appendix A A.2.3.l–18

For Office Use Only

Participant # __ __ __ __ __

Assignment #__ __ __ __ __

National Children’s Study

Birth Maternal Blood Data Collection Form

Part A: Administrative
Mother’s name:_____________________ Name of Hospital___________________ SC/VC ID: _______________________________	Date of collection:_____/_____/_______ Time of collection: _____:_____ am pm Staff ID________________ Hospital NCS
Part B: Precollection Questions
Do you have hemophilia or any bleeding disorder?				Yes No Don’t Know Refused
Do you take any blood-thinning medication, such as Coumadin or Warfarin?				Yes No Don’t Know Refused
Have you had cancer chemotherapy within the past 4 weeks?				Yes No Don’t Know Refused
Have you had any problems with a blood draw in the past?				Yes Fainting Light-Headedness Hematoma Bruising Other No Don’t Know Refused
When was the last time you had anything to eat or drink, other than water?				Time: _____: ____ am pm Don’t Know Refused
Part C: Samples Collected
Kit ID:_____________________________
Position of participant:			Sitting Reclining
Tube type		Sample ID
3 mL prescreened Lavender EDTA tube for metals
10 mL Red Top #1
10 mL Red Top #2
10 mL Red Top #3
Part D: Comments

DRAFT DRAFT DRAFT