Food Record Instructions

Form Approved

OMB No. 0920-0982

Expiration date: 09/30/2015

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 0920-0982.

Instructions:

• Please record everything you eat and drink from midnight to midnight.

• We are asking you to complete this record solely for the purpose of helping you remember 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, the Food Amounts Booklet, your duplicate salt samples, and any dietary supplements or non-prescription antacids you may have taken the day before the call 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 banana nut muffin made at home and salt was added when making the muffins, write in the total amount made (e.g. “made 1 dozen muffins”). Describe the total amount made in whatever makes sense for the food (“made 3 cups” of salsa, etc.)

• See below for a partially completed sample record

• Questions? Call 612-462-7751

Food Record Form (Sample)

Time	Food and Beverages	Total Amount Prepared (ONLY for home prepared foods with salt added in preparation)
6 am	tea
	banana nut muffin	1 dozen
	grapefruit
9 am	water
	diet coke
11 am	cheese quesadilla
	homemade salsa	3 cups made
	tortilla chips
	water