16.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Biospecimen Child Saliva Collection

Biospecimen Child Saliva Collection SAQ

Event:	12- Month
Participant:	Child
Domain:	Biospecimen
Type of Document: Allowable Mode: Allowable Method:	Self-Administered Questionnaire In Person PAPI
Recruitment Groups: Version: Release:	EH, PB, HI 1.0 MDES 3.0

Please complete this form when you collect a sample of your child’s saliva for the National Children’s Study. Thank you for taking the time to provide this information.

1. Were you able to collect your child’s saliva sample?

 Yes → Go to Question 2

 No → Go to Question 6

2. What day did you collect your child’s saliva sample? //

3. What time did you collect your child’s saliva sample? :  → (circle one) AM/PM

4. When was the last time your child had anything to eat or drink other than water before you collected your child’s saliva sample? Please enter date (month, day and year) and time.

Date: // Time: :  → (circle one) AM/PM

5. Who collected your child’s saliva sample?

 Mother

 Father

 Other → (please specify) ______________________________________

6. Is there anything you want to tell us about collecting your child’s saliva sample? If you could not collect the saliva sample, please tell us why.

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

Please call the local Study Center number on the last page, if you have any questions.

For Office Use Only:

Sample ID Label

Subject ID Label

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.