Study to Explore Early Development
Form Approved
OMB NO. __________
Exp. Date __________
Form Approved
OMB NO. 0920-0741
Exp. Date 6/30/2010
Thank you for your time and effort in this study. The following is a diary to keep track of what your child consumes during the week of the stool collection. Please be as detailed as possible in the spaces provided for the most accurate analysis of your child’s diet. Be sure to include any vitamins, herbs or other supplements. If your child spikes a temperature or seems to get the stomach flu please discontinue the food diary. Please document if this week’s intake was typical on the last day of recording.
Complete your diet record including details as in the example below:
Time eaten |
Amount EATEN |
What did you eat? |
Brand name |
Type (low fat, low sugar, creamy, crispy…) |
Preparation / Cooking method |
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6 pm |
½8 oz |
Water |
Evian |
Drinking Water |
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“ |
8 oz |
Diet Soda |
Coke |
Caffeine free |
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3 oz |
Steak |
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Rib Eye |
Trimmed fat, grilled |
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“ |
2 |
Celery sticks |
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2 pills |
Multiple Vitamin |
Flintstones |
children’s chewable |
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If you have any questions, please call <Principal Investigator>
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0741)
Day of week: M Tu W Th F Sa Su
Please circle the day of the week
Date:
Time eaten |
Amount EATEN |
What did you eat? |
Brand name |
Type (low fat, low sugar, creamy, crispy…) |
Preparation / Cooking method |
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File Type | application/msword |
File Title | Appendix H: Self Administered Packet 2 |
Author | Paige K. Gallito |
Last Modified By | zhv7 |
File Modified | 2007-08-24 |
File Created | 2007-08-24 |