0923-0048 Biological Testing Tracking Form

Form Approved

OMB No. 0923-0048

Exp. Date 6/30/2022

Appendix E2: ATSDR Biological Testing Tracking Form

ATSDR estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

Blood Lead Biological Testing Tracking Form:

Participant ID Number_______________________ Sample Collection Date_____________________

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 (as applicable)	Yes	No
Sign In	Yes	No
Consent/Parental Permission/ Assent Form	Yes	No
Questionnaire	Yes	No
Blood Draw	Yes	No
Gift Card Received	Yes	No