Form 1 Buccal Collection

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 3d b - English
PATH Study Data Collection Instruments:
Biospecimen Collection Forms – Buccal Cell
June 18, 2013

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

RS8c – Cheek Cell Data Collection Form

Respondent ID (Text Readable Barcode)
DCN
OMB Control Number: 0925-0664
Expiration Date: 11/30/2015
Date Printed

PATH Study Cheek Cell Data Collection Form

Interviewer-Administered

Part A: Administrative

Part C: Cheek Cell Collection Status

1.

1. Collection Status (Mark one):
Collected (End)
Not Collected
Attempted, Not Collected

Staff ID: Preprinted

2. Today’s Date:
|__|__|/|__|__|/|__|__|__|__|
M

M

D

D

Y

Y

Y

Y

2. Reason not collected (Mark one main reason):
Respondent refused, specify: _______________________________
Respondent refused, unwilling to give reason
Respondent ill/emergency
No time/busy
Uncomfortable with self-collection procedures
Defective/missing collection supplies
Mouth Condition, specify: __________________________________
Physical limitation, specify:
Other, specify: ______________________________________________

3. Buccal Cheek Cell Collection:
Agreed
Not Agreed (Go to Part C)
4. Cheek Cell Kit ID:
(Place Label Here)

Part B: Cheek Cell Collection Questions

1. When was the last time you had anything to eat or
drink other than water?
Date: |__|__|/|__|__|/|__|__|__|__|
M

M

D

D

Y

Time: |__|__| : |__|__|
H

Refused

H

M

Y

Y

Y

a.m.

M

2. When was the last time you brushed your teeth?
Date: |__|__|/|__|__|/|__|__|__|__|
M

M

D

D

Y

Time: |__|__| : |__|__|
p.m.

H

Refused

Don’t Know

3. Have you had cancer chemotherapy within the past 2 weeks?
Yes
No
Refused
Don’t Know

H

M

Y

Y

Y

a.m.

M

Don’t Know

p.m.

Population Assessment of Tobacco and Health (PATH) Study (NIDA)
Part D: Cheek Cell Collection Results

1. Collection Time:
|__|__| : |__|__|
H

H

2. Number of Collectors Used: ______
a.m.

p.m.

M M

3. TrekView temperature monitor activated
and included with specimen in biohazard
transport bag?
Yes

4. Time specimen and TrekView temperature monitor
placed in shipping container:
|__|__| : |__|__|
H H
M M

a.m.

p.m.

Part E: Comments



GO TO TOP OF FORM AND COMPLETE PART C CHEEK CELL COLLECTION STATUS

Public reporting burden for this collection of information is estimated to average 18 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 (0925-0664). Do not return the completed form to this address.