Form 1 BEEA Show Cards

Attachment 17.5:  BEEA IA Pre‐Visit Preparation Showcard 
In preparation for your interview, please record the product name,
active ingredient, and EPA registration number of the pesticides
you personally mixed, loaded, handled or applied in the past 12
months. This information is available from the product label. We
will collect this information at your visit.

Attention BEEA Study
Participants!
It is important that you make
the following preparations for
your study visit:

Product Name

Active Ingredient

Consent Form
Please take some time to review the consent form so you can be
prepared to complete it with the interviewer. The interviewer will address
any questions or concerns you may have at the beginning of your visit,
or you may also call us at the number below.

EPA
Registration #

Prescription Medications
We will be asking you about the prescription medications you take
regularly. Please assemble them in their original containers so they are
ready to review with the interviewer.
Pesticide Use in the Past 12 Months
We will be asking you about pesticides you have used in the past 12
months. This includes use of herbicides, insecticides, fungicides,
fumigants, or other chemicals used to kill plants, insects, fungi, molds, or
rodents. Do not include antibiotics, sanitizers, antimicrobial soaps, or
fertilizers. For each product, we will ask for the product name, active
ingredient, and EPA registration number, as well as about total days of
use, and dates of most recent use. Please use the back of this card to
help you prepare this information.
Urine Sample Collection
Please review the Directions for Urine Collection and the materials in the
collection kit. It is very important that you collect the urine sample on the
morning of your visit.

Please call us at 1-800-217-1954 if you have any questions.

Public reporting burden for this collection of information is estimated to average five 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 

Attachment 17.5:  BEEA IA Pre‐Visit Preparation Showcard 
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 (0925‐0406).  Do not return the completed form to this address. 

Attachment 17.6:  BEEA NC Pre‐Visit Preparation Showcard 

Attention BEEA Study
Participants!
It is important that you make
the following preparations for
your study visit:

In preparation for your interview, please record the product name,
active ingredient, and EPA registration number of the pesticides
you personally mixed, loaded, handled or applied in the past 12
months. This information is available from the product label. We
will collect this information at your visit.
Product Name

Active Ingredient

Consent Form
Please take some time to review the consent form so you can be
prepared to complete it with the interviewer. The interviewer will address
any questions or concerns you may have at the beginning of your visit,
or you may also call us at the number below.

EPA
Registration #

Prescription Medications
We will be asking you about the prescription medications you take
regularly. Please assemble them in their original containers so they are
ready to review with the interviewer.
Pesticide Use in the Past 12 Months
We will be asking you about pesticides you have used in the past 12
months. This includes use of herbicides, insecticides, fungicides,
fumigants, or other chemicals used to kill plants, insects, fungi, molds, or
rodents. Do not include antibiotics, sanitizers, antimicrobial soaps, or
fertilizers. For each product, we will ask for the product name, active
ingredient, and EPA registration number, as well as about total days of
use, and dates of most recent use. Please use the back of this card to
help you prepare this information.
Urine Sample Collection
Please review the Directions for Urine Collection and the materials in the
collection kit. It is very important that you collect the urine sample on the
morning of your visit.

Please call us at 1-800-424-7883 if you have any questions.

Public reporting burden for this collection of information is estimated to average five 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 (0925‐0406).  Do not return the completed form to this address.