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Appendix 4.1 Example of the Blood Collection Recording Form

Participant's identification code |__||__||__||__||__||__|

Blood collection exclusion criteria

Reasons for exclusion from blood collection
Reason Present Absent
Refused consent    
On anticoagulation therapy, e.g. warfarin    
History of fits    
Bleeding disorder (e.g. haemophilia, low platelets, etc.)    
Pregnant    
Other, specify:

 

    
Proceed with blood collection only, if all reasons for exclusion are absent.
Person completing the questionnaire:

Name:_______________________________________________

Signature: ____________________________________________

Date: |__||__|.|__||__|.|__||__||__||__|

 

Blood collection

Person taking blood sample(s) (identification code) |__||__|
Date (ddmmyyyy) |__||__|.|__||__|.|__||__||__||__|
Time of day (hhmm) |__||__|:|__||__|
How long has subject fasted (hours) |__||__|
Position of subject during the blood collection
1 = sitting
2 = supine		 |__|
Arm used for blood sample (if blood collection failed, code the arm where the last attempt was made)
1 = left
2 = right		 |__|
Number of tubes received
1 = all
2 = only |__| tubes
3 = none		 |__|

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