24-hour Urine Collection

24-Hour Urine Collection Form

*Attach this form to the urine collection container with a rubber band.*

Public reporting burden of this collection of information is estimated to average 50 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.

Name: _________________________ (last) ­_________________________ (first)

Specimen Collection Instructions

On the assigned day of collection, empty the contents of your bladder into the toilet after waking. Note the time and date in the space provided below.

Start time: __________ (hour) __________ (min) __________ (am/pm)

Date: __________ (month) __________ (day) __________ (year)

From this time on, collect all the urine that you pass during the day and the following morning in the plastic urine collection bottle(s). When you get up in the morning, empty the contents of your bladder into the plastic container and note the time in the space provided below.

Finish time: __________ (hour) __________ (min) __________ (am/pm)

Return the urine specimen bottle(s) and this sheet to the clinic the day after collection.

Questions? Contact the clinic manager at 612-462-7751

Store your urine container in a cool place such as a basement, a cooler with ice, or the refrigerator.