4 F100 Blood Collection

WHI

Form 100 - Blood Collection and Processing

Ver. 2 (Draft)
OMB # 0925-0414 Exp: XX/XXXX

Public reporting for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the information 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 is 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 (0925-0414). Do not return the completed form to this
address.

- Affix label hereClinical Center/ID: __ __

__ __ - ___ ___ ___ - __

First Name ________________________M.I.______
Last Name _________________________________

BLOOD REQUEST: (Home Visit)
Blood
Collection Tube

Three 7 ml
Red

Cryovials

Four 1.8 ml
Serum

Two 4.5 ml
Light Blue
Three 1.8 ml
Plasma

One 10 ml
Lavender

1 Buffy coat

Lipid Panel
Three 1.8
ml Plasma

1 Buffy
Coat

1 RBC

BLOOD COLLECTION
1.

Date blood drawn:

-

2.

Drawn by:

-

3.

Contact type:

4.

Visit type:

5.

Time drawn:

(M/D/Y)

-

____________________________________

4 Home Visit
8 Other
X Non-Routine

4
:

(Hr:Min)

1 AM 2 PM

BLOOD COLLECTION CHECKLIST
6.

"How long since you had anything to eat or drink besides water?"

hours

(If you are drawing for a lipid panel and this is less than 12 hours, do not draw
blood. Arrange a time when the woman can come in for a fasting blood draw.)
7.1.

"Have you engaged in any vigorous physical activity in the last eight hours?"

0 No 1 Yes
7.2.

"Have you taken any aspirin or anti-inflammatory agents in the last 48 hours?"

0 No 1 Yes
8.

WHI blood sample number:

- Affix
blood
sample
"Form"
label here
and on
back of
form -

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Form 100 - Blood Collection and Processing

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Form 100 - Blood Collection and Processing

Ver. 2 (Draft)

BLOOD PROCESSING
9.

Processed by:

10.

Time began centrifugation:

:

(Hr:Min)

12.

Time sample placed in cryovials:

:

(Hr:Min)

13.

Time cryovials placed in freezer:

:

(Hr:Min)

14.

WHI blood sample number:

_______________________________

1 AM 2 PM
1 AM 2 PM
1 AM 2 PM

- Affix
blood
sample
"Form"
label here
and on
back of
form -

Orig Tube
Color

Sample

15.
Cryovial
Number

Red

Serum

0 2

Red

Serum

0 3

Red

Serum

0 4

Red

Serum

0 5

Light Blue

Citrate plasma

0 6

Light Blue

Citrate plasma

0 7

Light Blue

Citrate plasma

0 8

Lavender 10ml

EDTA plasma

1 0

Lavender 10ml

EDTA plasma

1 1

Lavender 10ml

EDTA plasma

1 2

Lavender 10ml

Buffy Coat

1 3

Lavender 10ml

RBC

1 4

Light Blue 10 ml

Buffy Coat

2 0

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16.
Mark if Sample
Processed

1
1
1
1
1
1
1
1
1
1
1
1
1

WHI

Form 100 - Blood Collection and Processing
Spanish translation not needed; interviewer administered form
Instructions to WHI Staff under development

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Ver. 2

Draft 11: 08/02/94