Form 11 Att.14 24 hr Urine Collection Log

Attachment 14

24-Hour Urine Collection Log	OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 60 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA (####-####).

Directions for Collecting First Morning Void and 24-hour Urine Sample

As part of our study, we are asking you to collect a first morning void urine sample and a 24-hour urine sample. You will need to begin collecting your sample on the morning of ______________. In this kit, you will find all of the materials needed to collect your urine samples and temporarily store them until you bring it back to our clinic.

The first morning void urine collection kit contains the following:

• Screw top first morning void collection container (pre-labeled)

• Leak-proof plastic bag

• Brown paper bag

• Absorbent pad

The 24 hour urine collection kit contains the following:

• Two 3L urine collection containers

• Urinal for males or collection ‘hat’ for females

• Funnel

• PABA Tablets (3 x 100mg)

• Directions for Collecting 24-Hour Urine Sample

• 24-Hour Urine Collection Questionnaire

• Safety Pin

Your 24 hour urine collection containers must be kept in a cool area away from direct sunlight at all time.

Please do not take medications containing acetaminophen, sulphonamides, or vitamin supplements during the 24-hour urine collection period.

To collect the first morning void urine sample and the 24-hour urine sample, please follow the directions below:

first morning void urine sample

1. To help you remember to collect your wake-up urine sample, leave the first morning void urine collection container on the toilet seat lid the night before.

2. When you wake up in the morning, wash your hands before opening the collection container.

3. Urinate directly into the container.

4. Replace the top on the first morning void collection container and screw it on tightly. Place the sample inside the leak-proof plastic bag with the absorbent pad and then inside the brown paper bag.

5. Store the first morning void sample in the refrigerator.

24-hour urine sample

6. Enter the date and time of this first morning void urination for Question #1 on the 24-Hour Urine Questionnaire.

7. Take one PABA tablet with one full glass of water at breakfast time or within one hour after you wake up, whichever occurs first. Please ensure that you take the first PABA tablet after you have voided your first urine. Enter the time you took this first PABA tablet for Question #2 on the 24-Hour Urine Questionnaire.

8. Pin the safety pin to your undergarments. This is a visual cue to remind you to collect your urine each and every time you use the bathroom during the 24-hour collection period.

9. For the next 24-hour time period, you must collect all of your urine. For females: place the hat on the toilet seat and collect the entire amount. For males: urinate directly into the urinal, collecting the entire amount. Pour the urine from the hat/urinal into 3L collection container using the funnel, avoiding any spillage. If possible, pass urine before passing stool. Replace the top on the 3L collection container immediately to minimize exposure to the air. Please ensure the pour spout is in the closed position (pushed-down).

10. If you accidentally miss collecting a sample, please enter the time and approximate amount of the missed sample for Questions #3 and #4 on the 24-Hour Urine Questionnaire. It is very important that we know if any urine has been missed. Continue your collection.

11. Take the second PABA tablet with one full glass of water at lunch, and the third PABA tablet at dinner. Enter the time you took the second and the third PABA tablet for Question #2 on the 24-Hour Urine Questionnaire.

12. Upon awakening in the morning the next day, collect your first morning urine. This will be your last urine collection. Enter the date and time of your final urine sample for Question #5 on the 24-Hour Urine Questionnaire.

13. Complete Question #6 on the 24-Hour Urine Questionnaire.

14. Put filled urine containers in the bag provided. Place the completed questionnaire in the plastic ziploc bag and place it in the outside pocket of the bag with the urine containers. Please, bring back the 24 hour urine and the first morning void urine to our clinic. You do not need to return the funnel or hat/urinal.

The 3L collection containers must be kept in a cool area away from direct sunlight at all times.

Tips to help you remember to collect all of your urine:

• Attach the safety pin provided to your underclothes.

• When at home, leave the hat/urinal on top of the toilet seat.

• When away from home, keep your supplies close by at all times.

If you have any questions or concerns, please contact

________________________________

Thank you for providing this sample!

Interactive Diet and Activity Tracking in AARP (iDATA)

Urine Collection Questionnaire

You will begin to collect your 24-hr urine sample the morning of ­­­_____________________________

1. Enter the date and time you collected your first urination on the morning you start your 24-hour urine collection.

Date: |___|___| |___|___| |_2_|_0_|__|__| Time: |___|___|:|___|___| am/pm

MO DAY YEAR

2. Record the time you take each PABA tablet.

Tablet 1: Time: |___|___|:|___|___| am/pm

Tablet 2: Time: |___|___|:|___|___| am/pm

Tablet 3: Time: |___|___|:|___|___| am/pm

3. Did you miss collecting any sample of your urine during this 24-hour period?

|___| Yes |___| No  Skip to Question #5

4. If you missed collecting any urine, please record the time of the missed collection and estimate the amount of urine voided.

Time: |___|___|:|___|___| am/pm estimated amount: _____________ oz.

Time: |___|___|:|___|___| am/pm estimated amount: _____________ oz.

5. Enter the date and time of your final urine sample on the morning after you started this 24-hour urine collection period.

Date: |___|___| |___|___| |_2_|_0_|__|__| Time: |___|___|:|___|___| am/pm

MO DAY YEAR

6. Record all prescription and nonprescription medications you took during the 24-hour urine collection period in the space provided below:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Thank you for providing this sample!