Blood Collection

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Blood Collection
Participant ID	_______________________
Name of Assessor	__________________(free type)
Name of Data Clerk	__________________(free type)
Date of assessment	______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
Time of blood collection	__________________(4 digits)
Location of blood collection	__________________(free type)
Number of specimen tubes filled	__________ (1 digit)
Zika Virus	PRNT
Liver function	Alanine transaminase (ALT) Aspartate aminotransferase (AST)
Kidney function	Creatinine
Thyroid dysfunction	Free T3 Free T4
Lead levels	Blood lead levels
Anemia	Hematocrit Serum ferritin Serum iron Total iron binding capacity (TIBC)