TWQ Sample Distribution Script

OMB Control Number: 0925-0593

Expiration Date: 07/31/2013

Environmental Tap Water TWQ Sample Distribution Script, Phase 2e

Environmental Tap Water Pesticide (TWQ) Sample Distribution Script

(EH, PB, HI) V1.0

Event:	Pregnancy Visit 1
Participant:	Pregnant Woman
Domain:	Environmental
Type of Document:	Script
Recruitment Groups:	EH, PB, HI

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Environmental Tap Water TWQ Sample Distribution Script

Here is a Tap Water TWQ sample collection kit so that you may collect the TWQ sample yourself. Your collection of this TWQ sample will help us learn more about the tap water in homes. Also, it will help us learn if participants have problems with the procedures for collecting tap water samples, so that one day we may mail the kits to participants directly.

To collect the TWQ sample, you will fill two bottles with water from your kitchen faucet or other tap and complete the Tap Water TWQ Questionnaire.

You will then package the bottles on ice packs and ship them to the designated laboratory by FedEx using the pre-paid, self-addressed Fedex label and shipping container provided.

The Tap Water TWQ Questionnaire will be mailed to our office by regular mail in the enclosed pre-paid, self-addressed envelope.

Please place the ice packs provided in the kit in your freezer as soon as possible. Ice packs should be frozen when you ship the TWQ sample.

If possible, on the day of sample collection, before collecting the sample, avoid handling or using the following: caffeine, tobacco, home cleaning agents, or personal care products, such as antibacterial soaps, hand sanitizers, or lotions.

It is important that you complete the collection of each sample before starting the collection of other samples. Please keep the TWQ sample separate from TWF sample to avoid mixing of two different samples. TWQ and TWF samples should be packaged and shipped to the designated laboratories in separate shippers.

Do you have any questions about the Tap Water TWQ sample collection kit?

IF ASKED WHAT TWQ MEANS: TWQ is a code for the laboratory so they know the difference in the two sample types collected. There are two sample codes – a TWQ and a TWF sample.

THIS SCRIPT MAY BE MODIFIED AS APPROPRIATE IF OTHER ENVIRONMENTAL SAMPLE COLLECTION KITS ARE BEING DISTRIBUTED AT THIS VISIT.

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.