16.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Biospecimens Breast Milk Collection

Biospecimen Breast Milk Collection SAQ

Event:	1 Month, 3 Month
Participant:	Mother
Domain:	Biospecimen
Type of Document: Allowable Mode: Allowable Method:	Self-Administered Questionnaire In Person PAPI
Recruitment Groups:	EH, PB, HI
Version:	1.0
Release:	MDES 3.0

As part of the National Children’s Study, we are asking you to provide a breast milk sample from one breast. Please follow the instructions provided in the breast milk collection kit to collect the sample.

After you have collected the breast milk sample, please complete the information on both sides of this form.

1. On what date did you collect the sample? //

2. At what time did you collect the sample? :  → (circle one) AM/PM

3. How long did it take you to collect this sample?

 0-10 minutes

 11-20 minutes

 Over 20 minutes

4. How long before collecting the breast milk sample did you last breast-feed your baby or pump milk from this breast?

 Less than 2 hours

 2-4 hours

 Over 4 hours

5. Did you use a pump to collect the sample?

 Yes → Go to Question 6

 No → Go to Question 8

6. What type of pump did you use to collect the sample?

 Electric pump

 Hand pump

7. What is the brand of the pump you used to collect the sample? (Mark one)?

 Medela^®

 AVENT^®

 Playtex^®

 Ameda^®

 Evenflo^®

 Lansinoh^®

 Other—specify: ____________________

 Don’t know

8. Did you completely empty the breast when collecting the sample?

 Yes

 No

 Don’t Know

9. During the 2 hours prior to collecting the breast milk sample, did you eat or drink any caffeinated beverage or food (for example, coffee, tea, soda, chocolate)?

 Yes

 No

10. During the 2 hours prior to collecting the breast milk sample, did you drink any alcohol?

 Yes

 No

11. Please write down the name of any prescription, over-the-counter, homeopathic, or non-traditional medicines you have taken in the last 24 hours (including prenatal vitamins). Please be specific. For example, if you took Robitussin DM®, write Robitussin DM®, not Robitussin®. If you did not take any prescription or over-the-counter medications in the last 24 hours, please mark None.

 None

12. How long after collecting your sample did you place it in the freezer?

 0-10 minutes

 11-20 minutes

 Over 20 minutes

Thank you for participating in the National Children’s Study and for taking the time to complete this information.

Please call the local contact number located on the last page, if you have any questions.

For Office Use Only:

Place Breast Milk

Kit Label Here

A B |__|__|__|__|__|__|__| - D C |__|__|

Mother’s Participant ID

Visit Type/Event ID

Insert local contact information here

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.