Attachment 5
Fasting Blood Protocol and Form |
OMB#: ####-#### EXP.DATE: ##/##/#### |
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN |
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Public reporting burden for this collection of information is estimated to average 10 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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 (####-####). |
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Fasting Instructions for Clinic Blood Collection
Do not eat or drink anything, other than water after midnight the night before your appointment.
On the morning of your appointment, drink 1 to 2 glasses of water.
Take your normal medications, except vitamins, minerals, or other nutritional supplements.
If you are required to take your medication(s) with food, bring your medication(s) with you to the study clinic. We will provide a small snack after your blood has been drawn.
Do not drink coffee or tea.
Do not eat any food or chew gum.
Do not take vitamins, minerals, or other nutritional supplements.
Fasting Blood collection
PART 1: PRE-COLLECTION QUESTIONS
I would like to ask you a few questions before we begin with the blood draw.
Do you have hemophilia?
Yes 1 (do not draw blood)
No 2 (continue)
Are you currently taking blood-thinning medication (exclude aspirin)?
Yes 1 (do not draw blood)
No 2 (continue)
Have you received chemotherapy or blood products in the past four weeks?
Yes 1 (do not draw blood)
No 2 (continue)
Have you ever had your blood drawn before?
Yes 1
No 2 (skip to question 7)
Have you ever had problems when your blood was drawn?
Yes 1
No 2 (skip to question 7)
What types of problems have you had?
Bruising 1
Felt faint/dizzy/lightheaded 2
Problems with veins 3
Other (specify) 6
In the past 24 hours, have you smoked any cigarettes?
Yes 1 (continue)
No 2 (skip to question 9)
How many cigarettes have you smoked in the past 24 hours?
Number of cigarettes |__|__|__|
(1 pack=20 cigarettes)
When was the last time you had anything to eat or drink other than water?
Date
Time
________ hours ago (8 hour fast required. If less than 8
hours Subject may return on another day)
Have you taken any vitamin supplements today?
Yes 1 (continue)
No 2 (skip to question 12)
What did you take?
Name (i.e. Multi vitamin, Vitamin C, Vitamin D)
___________________________________________
Dose ____________________________
Have you taken any medication today?
Yes 1 (continue)
No 2 (Go to Part 2)
What did you take?
Name
Dose
Thank you for answering these questions. We’ll now begin the blood draw.
PART 2: BLOOD COLLECTION
Time and date of collection: |__|__|:|__|__| am pm |__|__|/|__|__|/|__|__|
Mo Day Year
Collected by: _____________________________________
Tubes Collected (circle): |
Tube 1 |
Full 1 |
Partial 2 |
None 0 |
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Tube 2 |
Full 1 |
Partial 2 |
None 0 |
If blood is not drawn, please circle reason code(s) and explain:
Unsuccessful draw (2 attempts) 1
Blood draw stopped 2
Refusal 3
Other 6
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Susan Yurgalevitch |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |