Table Salt Collection

Form Approved

OMB No. 0920-xxxx

Expiration date: xx/xx/xxxx

Table Salt Collection

(SUB STUDY PARTICIPANTS)

Public reporting burden of 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 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.

Participant Name:

Participant ID:

Part 1: Table Salt Collection

Date of salt collection:

Was the study provided salt used at the table?

O Yes

O No, did not use study salt

O No, did not add salt to food at the table

If ‘No, did not use study salt’, what type of salt was used at the table?

O Ordinary salt including sea salt, iodized and non-iodized salt, kosher salt

O Lite salt- brand name:__________________________

O Salt substitute- brand name:________________________

O Other- describe:__________________________

O Don’t know

Record the following information about each meal or snack you added salt to food at the table (leave blank if you did not add any salt to food at the table)

Meal Name (e.g. lunch, snack) Approximate Time Food(s) salt was added to

Part 2: Salt Added in Home Cooking

Date of salt collection:

Was the study provided salt used at home during cooking?

O Yes

O No, did not use study salt

O No, did not add salt to food at the table

If ‘No did not use study salt’, what type of salt was used while cooking?

O Ordinary salt including sea salt, iodized and non-iodized salt, kosher salt

O Lite salt- brand name:__________________________

O Salt substitute- brand name:________________________

O Other- describe:__________________________

O Don’t know

Record the following information about each meal or snack you added salt to food while cooking (leave blank if you did not add any salt to food while cooking)

Meal Name (e.g. lunch, snack) Approximate Time Food(s) salt was added to