Phlebotomist Safety Exclusion Questions

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x

Attachment 4g. Phlebotomist Safety Exclusion Questions

Safety Exclusion Questions (All Participants)

Q1. “Do you have hemophilia?”

If yes, the participant is ineligible for a blood draw. Inform the participant and thank them for their willingness to participate in this component.

If no, the participant is eligible for a blood draw. Proceed with sample collection.

Q2. Have you received cancer chemotherapy in the past four weeks?

If yes, the participant is ineligible for a blood draw. Inform the participant and thank them for their willingness to participate in this component.

If no, the participant is eligible for a blood draw. Proceed with sample collection.

Additional Safety Exclusion Questions (for participants < 18 years of age)

Q3. Do you weigh less than 25 pounds?

If yes:

How much do you weigh? _______________________

Maximum blood draw is = (weight/2.2)*3

ATSDR estimates the average public reporting burden for this collection of information as 2 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 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

If no, the participant is eligible for the maximum blood draw required by the study (15mL x 2 collections).