Questionnaire for Men in Semen Sub-Study

Form Approved

OMB Control No. 0920-1140

Exp. Date: 10/31/2017

Attachment N. Questionnaire for men in semen sub-study

Boxes to be completed by ZIPER staff

ZIPER ID:

VISIT CODE

_____ _____ _____

SAMPLE COLLECTION DATA

SAMPLE PRODUCTION	SAMPLE RECEIPT
GENES Fertility Clinic Auxilio Mutuo Home Other:_____________	GENES Fertility Clinic Auxilio Mutuo Home Other:_____________
COLLECTION DATE ­­­­­ (mm/dd/yy) ________________	RECEIPT DATE ­­­­­ (mm/dd/yy) ________________
COLLECTION TIME _______________ AM PM	RECEIPT TIME _______________ AM PM
ABSTINENCE (including masturbation) (days) ________

LABORATORY FINDINGS

PHYSICAL SEMEN ANALYSIS – TIME _______________ AM PM

Characteristic	Appearance	Characteristic	Appearance
Liquefaction (< 30 min)	Complete incomplete	WBC’s/hpf	(Normal < 2/hpf)
Viscosity	Normal increased	Debris	(Normal + 1- + 3)
Turbidity	Transparent translucent opaque	pH	(Normal= 7.2-8.0)
Color	White yellow clear other	Bacteria	Yes No Moderate
Agglutination/(type)	YES NO Type: (~%):	Other	Round Cell’s ( ); Epit. C’s ( )
Hematospermia	YES NO

QUANTITATIVE/ QUALITATIVE SEMEN ANALYSIS

Characteristics	Observed values	Reference Values
Volume (ml)		(1.5-5.0 ml)
Concentration (x 106/ml)		(> 20 x 106/ml) *Mean Conc. (see below)
Count (x 106)		(> 40 x 106)
Motility (%)		(> 40 %)
Total motile sperm (x 106)		(> 20 x 106)
Progressive motility (%)		(+3/+4; > 25%)
Estimated morphology (% Normal)		(> 14%) Kruger’s Strict Criteria
Total Functional Sperm Fraction		(> 10 x106/ejaculate)

*CONC 1 x 10⁶/ml _________ *CONC 2 x 10⁶/ml ________ *MEAN CONC x 10⁶/ml _________

SPERM PROGRESSION/VIABILITY TEST

Time	Grade 1 (%)	Grade 2 (%)	Grade 3 (%)	Grade 4 (%)	Total Motility (%)
Hour 1

SPERM MEMBRANE INTEGRITY/FUNCTIONAL TESTS

If motility < 50 %, determine Live/Dead ratio with Supravital Stain (%):

STRICT SPERM MORPHOLOGY

Normal/abnormal forms (%):

Normal (> 14%) Kruger’s Strict Criteria

Head (%)		Tail (%)		Immature (%)
Nuclear (%)		Neck-Midpiece (%)		Amorphous (%)
Acrosome (%)		Cytoplasmic droplets (%)

Preliminary comments and diagnostic: _________________________________________________________ ___________________________________________________________________________________________
Person(s) who analyzed specimen: _____________________________________________________________________

Public reporting burden of this collection of information is estimated to average 20 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1140