Form 1 Blood Collection

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

Attachment 3d a - English
PATH Study Data Collection Instruments:
Biospecimen Collection Forms - Blood
June 18, 2013

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

RS8b – Blood Data Collection Form

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

PATH Study Blood Data Collection Form

Health Professional-Administered

Part A: Administrative

Part C: Blood Collection Status

1.

1. Collection Status (Mark one):
Collected (End)
Not Collected
Attempted, Not Collected
2. Reason not collected (Mark one main reason):
Respondent refused, specify:
______________________
Respondent refused, unwilling to give reason
Safety exclusion
No time/busy
No show
Respondent ill/emergency
Defective/missing collection supplies
Physical limitations, specify:
______________________
Other, specify:
_________________________________

Staff ID: Preprinted

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

M

D

D

Y

Y

Y

Y

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

Part B: Blood Suitability Questions

1. Do you have hemophilia or any bleeding
disorder?
Yes (Go to Part C)
Refused (Go to Part C)
No
Don’t Know (Go to Part C)

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

3. Have you had any problems with a blood draw in
the past?
Yes
Refused (Go to Part D)
No (Go to Part D)
Don’t Know (Go To Part D)

4. What problems have you had with a blood draw in
the past? (Mark allHave
thatyou
apply.)
had any problems with a blood draw in the pa
Fainting
Light-headedness
Hematoma
Bruising
Other, specify
_________________________

Population Assessment of Tobacco and Health (PATH) Study (NIDA)
Part D: Blood Tube Status

Blue Top Tube (BL01)
Red Top Tube #1 (RD01)
Red Top Tube #2 (RD02)
Lavender Tube #1 (LV01)
Lavender Tube #2 (LV02)
PAXgene Tube (PX01)

Full draw
Full draw
Full draw
Full draw
Full draw
Full draw

Short draw
Short draw
Short draw
Short draw
Short draw
Short draw

No draw
No draw
No draw
No draw
No draw
No draw

Part E: Blood Collection Results

2. TrekView temperature monitor activated and included with
specimen in amber transport bag?
Yes

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

H

a.m.

p.m.

M M

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

H

M

a.m.

4. Problems with the blood draw? (Mark all that apply.)
No problems
Fainting
Light-headedness
Hematoma
Bruising
Other, specify ________________

p.m.

M

Part F: Comments



GO TO TOP OF FORM AND COMPLETE PART C BLOOD 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.