Att 12B_Food Record Instructions

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Food Record Instructions

Public reporting burden of this collection of information is estimated to average 15 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, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

Please record everything you eat and drink from midnight to midnight on the following day:

Instructions:

• We are asking you to complete this record solely for the purpose of helping you recall what you ate and drank when we call you over the telephone to complete a 24-hour dietary recall. Make sure you have the completed record and the Food Amounts Booklet with you for your scheduled telephone recall.

• As you go throughout your day write down the foods and beverages you ate and the approximate time. You can write in the amount of food you ate (e.g. 3 slices, 2 mugs, etc.) if you want, but you don’t have to.

• If you ate a food that was prepared at home with salt added in preparation, write-in a description of the total amount of food prepared. For example, if you ate a sugar cookie made at home and salt was added when making the cookies, write in the total amount made (e.g. “made 3 dozen cookies). For in whatever way you can (e.g. “made 4 cup”; “made 8 ½ x 11” pan”, etc.)

• See below for a partially completed sample record

• Questions? Call xxx-xxx-xxxx

• Thanks

Food Record Form (Sample)

Time	Food and Beverages	Total Amount Prepared (only for home prepared foods with salt add in prep.)
6 am	tea
	doughnut holes
	grapefruit
9 am	water
	diet coke
11 am	Cheese quesadilla
	Fresh salsa	3 cups made
	tortilla chips
	water