Postage: • Place the Uriswab Bag (1 & 2) and the completed questionnaire into the reply paid envelope. • Seal the envelope. • Deposit the reply paid envelope in an Australia Post box. QUESTIONNAIRE WEEK 3 STUDY ID: ABOUT OMEGA MOUTHWASH 1. In the last 21 days (i.e. 3 weeks), how many days did you use the OMEGA mouthwash? (Please estimate the number of days from 0 to 21). ____________________ days ast 21 days, on average, how many times did you use the OMEGA mouthwash per day? dd mm yy Date: ________/________/ Your Study ID OMEGA Bag 1 BIOHAZARD SPECIMEN ONLY OMEGA Bag 2 Reply Paid 80000 OMEGA Attn: Eric Chow Melbourne Sexual Health 580 Swanston Street Carlton 3050 No stamp required If posted in Australia Questionnaire: • Wash your hands with soap and water. • Complete the questionnaire provided. QUESTIONNAIR WEEK 12 STUDY ID: d ABOUT OMEGA MOUTHWASH 1. In the last 21 days (i.e. 3 weeks), how many days did you use (Please estimate the number of days from0 to 21). _______ 2. In the last 21 days, on average, how many times did you Never in the last 21 days 2 times p 1 time per day 3 or mo 3. In the last 21 days did you rinse or gargle with Rinse only Gargle only 4. In the last 21 days, on average, how Less than 10 seconds per r 10-30 seconds time per ri 60 seconds per rins han 60 secon l Date: __ Seal and bag sample: • Place the Uriswab swab, making sure to screw the lid on tight into bag 1 and seal. • Place Bag 1 into bag Bag 2 and seal bag 2. OMEGA Bag 1 OMEGA Bag 1 BIOHAZARD SPECIMEN ONLY OMEGA Bag 2 Completing the sample collection: • Put the lid back on the saliva jar and discard. • Place the Uriswab back into the tube and seal firmly. • Write the date you collected the saliva sample on the Uriswab. R u b b i s h B i n S a li v a J a r Collecting the saliva sample: • Open the small yellow top tube (Uriswab) you will see a sponge attached to the lid. • Swirl the absorbent sponge in the saliva for 30 sec. You may have to tilt and rotate the sponge several times into the saliva to ensure maximum coverage of the sponge area. S a l i v a J a r S a l i v a J a r Preparing for the saliva sample: • Accumulate saliva in your mouth for about 30 sec to get a reasonable saliva sample. • Spit as much saliva into the saliva jar as possible. To start: • Wash your hands thoroughly with soap and water. • Remove the lid from the saliva jar in preparation to spit into the jar. S a l i v a J a r QUESTIONNAIRE WEEK 3 STUDY ID: b What’s in the kit: a) A padded bag for reply paid postage b) A questionnaire c) 2 plastic zip-lock bags (OMEGA Bag 1 & OMEGA Bag 2) d) A small yellow topped tube (Uriswab) e) A large yellow topped jar (saliva jar) f) This instruction sheet about saliva collection 3 2 1 4 7 6 5 8 How to take a Saliva Sample Reply Paid 80000 TEST ME Attn: Candice Fuller Melbourne Sexual Health 580 Swanston Street Carlton 3050 No stamp required If posted in Australia BIOHAZARD SPECIMEN ONLY OMEGA Bag 2 OMEGA Bag 1 f d c a S a liv a j a r e 3 2 1 4 7 6 5 8 How to take a saliva sample Version: 2.2 | 14/02/2017
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How to take a saliva sample - MSHCmshc.org.au/omega/assets/salivasample_directions_email.pdf · Preparing for the saliva sample: • Accumulate saliva into your mouth for about 30
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Postage:• Place the Uriswab Bag (1 & 2) and the completed questionnaire into the reply paid envelope.• Seal the envelope.• Deposit the reply paid envelope in an Australia Post box.
QU
ESTION
NA
IRE
WEEK 3
STUD
Y ID:
AB
OU
T OM
EGA M
OU
THW
ASH
1. In the last 21 days (i.e. 3 w
eeks), how m
any days did you use the OM
EGA m
outhwash? (P
lease
estimate the num
ber of days from 0 to 21). ____________________ days
2. In the last 21 days, on average, how
many tim
es did you use the OM
EGA m
outhwash per day?
N
ever in the last 21 days
1 tim
e per day
2 times per day
In the last 21 days did you rinse or gargle with the O
MEG
A mouthw
ash?
dd mm
yy
Date: ________/________/
Your Study ID
OMEGABag 1
BIOHAZARD
SPECIMEN ONLY
OMEGABag 2
Reply Paid 80000
OMEGA
Attn: Eric Chow
Melbourne Sexual Health
580 Swanston Street
Carlton 3050
No stamp required
If posted in Australia
Questionnaire:• Wash your hands with soap and water.• Complete the questionnaire provided.
QUESTIONNAIRE
WEEK 12
STUDY ID:
dd
mm
ABOUT OMEGA MOUTHWASH
1. In the last 21 days (i.e. 3 weeks), h
ow many days did you use the OMEGA mouthwash?
(Please estimate the number of days from0 to 21). _
___________________ days
2. In the last 21 days, on average, how many times did you use the OMEGA mouthwash per day?
Never in the last 21 days
2 times per day
1 time per day
3 or more tim
es per day
3. In the last 21 days did you rinse or gargle with the OMEGA mouthwash?
Rinse only
Gargle only
4. In the last 21 days, on average, how long did you use the OMEGA mouthwash per rinse/gargle?
Less than 10 seconds per rinse/gargle
10-30 seconds time per rin
se/gargle
30-60 seconds per rinse/gargle
More than 60 seconds per rinse/gargle
5. When did you usually use the OMEGA mouthwash during the study period (last 12 weeks)?
(Please ‘P’ the most appropriate category)
AMorning
BAfternoon
CNight
DBefore/after m
eal
EF
Date: _
_______/________/
Seal and bag sample:• Place the Uriswab swab, making sure to screw the lid on tight into bag 1 and seal.• Place Bag 1 into bag Bag 2 and seal bag 2.
OMEGABag 1
OMEGABag 1
BIOHAZARD
SPECIMEN ONLY
OMEGABag 2
Completing the sample collection:• Put the lid back on the saliva jar and discard.• Place the Uriswab back into the tube and seal firmly.• Write the date you collected the saliva sample on the Uriswab.
RubbishBin
Saliva Jar
Collecting the saliva sample:• Open the small yellow top tube (Uriswab) you will see a sponge attached to the lid. • Swirl the absorbent sponge in the saliva for 30 sec. You may have to tilt and rotate the sponge several times into the saliva to ensure maximum coverage of the sponge area.
Saliva Jar
S aliva Jar
Preparing for the saliva sample:• Accumulate saliva in your mouth for about 30 sec to get a reasonable saliva sample.• Spit as much saliva into the saliva jar as possible.
To start:• Wash your hands thoroughly with soap and water.• Remove the lid from the saliva jar in preparation to spit into the jar.
S aliva Jar
1
QUESTIONNAIRE WEEK 3
STUDY ID:
ABOUT OMEGA MOUTHWASH 1. In the last 21 days (i.e. 3 weeks), how many days did you use the OMEGA mouthwash? (Please
estimate the number of days from 0 to 21). ____________________ days
2. In the last 21 days, on average, how many times did you use the OMEGA mouthwash per day?
Never in the last 21 days 1 time per day 2 times per day 3 or more times per day
3. In the last 21 days did you rinse or gargle with the OMEGA mouthwash?
Rinse only Gargle only Both rinse and gargle
4. In the last 21 days, on average, how long did you use the OMEGA mouthwash per rinse/gargle?
Less than 10 seconds per rinse/gargle 10-30 seconds time per rinse/gargle 30-60 seconds per rinse/gargle More than 60 seconds per rinse/gargle
ABOUT HEALTH INFORMATION5. In the last 21 days, have you taken antibiotics for any reason?
Yes. Name of antibiotic(s): ________________ Reason(s): ___________________ No Unsure
dd mm yyDate: ________/________/
b
What’s in the kit:a) A padded bag for reply paid postageb) A questionnaire c) 2 plastic zip-lock bags (OMEGA Bag 1 & OMEGA Bag 2)d) A small yellow topped tube (Uriswab) e) A large yellow topped jar (saliva jar) f) This instruction sheet about saliva collection
Postage:
• Place the Uriswab Bag (1 & 2) and the completed
questionnaire into the reply paid envelope.
• Seal the envelope.
• Deposit the reply paid envelope in an Australia
Post box. Questionnaire
Testme.org.au
Thank you for taking the
time to fill in this survey
which will help us to evaluate this new service.
Your comments will help
us improve the service.This survey should only
take 10 mins of your time.
OMEGABag 1
BIOHAZARD
SPECIMEN ONLY
OMEGABag 2
Reply Paid 80000OMEGAAttn: Eric ChowMelbourne Sexual Health580 Swanston StreetCarlton 3050 No stamp required
If posted in Australia
Questionnaire:
• Wash you hands with soap and water.
• Complete the questionnaire provided.
QUESTIONNAIREWEEK 12
STUDY ID:
dd mm
ABOUT OMEGA MOUTHWASH 1. In the last 21 days (i.e. 3 weeks), how many days did you use the OMEGA mouthwash?
(Please estimate the number of days from0 to 21). ____________________ days2. In the last 21 days, on average, how many times did you use the OMEGA mouthwash per day?
Never in the last 21 days 2 times per day
1 time per day 3 or more times per day
3. In the last 21 days did you rinse or gargle with the OMEGA mouthwash? Rinse only
Gargle only
4. In the last 21 days, on average, how long did you use the OMEGA mouthwash per rinse/gargle? Less than 10 seconds per rinse/gargle
10-30 seconds time per rinse/gargle 30-60 seconds per rinse/gargle
More than 60 seconds per rinse/gargle5. When did you usually use the OMEGA mouthwash during the study period (last 12 weeks)?
(Please ‘P’ the most appropriate category)
AMorning
BAfternoon
CNight
DBefore/after meal
EF
Date: ________/________/
Seal and bag sample:
• Place the Uriswab tube into Bag 1, making
sure to screw the lid on tight.
• Place Bag 1 into bag Bag 2 and seal bag.
OMEGABag 1
OMEGABag 1BIOHAZARD
SPECIMEN ONLY
OMEGABag 2
Completing the sample collection:
• Put the lid back on the saliva jar and
discard.
• Write the date of when you collected the
sample on the Uriswab.
Rubbish
Bin Sali va
Jar
Collecting the saliva sample:
• Open the small yellow top tube (Uniswab) you will
see a sponge attached to the lid.
• Swirl the absorbent sponge in the saliva for 30 sec.
You may have to tilt and rotate the sponge several
times into the saliva to ensure maximum coverage
of the sponge area. Saliva
Jar
Saliva Jar
Preparing for the saliva sample:
• Accumulate saliva into your mouth for about
30 sec to get a reasonable saliva sample.
• Spit as much saliva into the saliva jar
as possible.
To start:
• Wash your hands throughly with soap and water.
• Remove the lid from the saliva jar in preparation
to spit into the jar.
Sal iva
Jar
QuestionnaireTestme.org.au
Thank you for taking the
time to fill in this survey
which will help us to
evaluate this new service.
Your comments will help
us improve the service.
This survey should only
take 10 mins of your time.
b
What’s in the kit:
a) A padded bag for reply paid postage
b) A questionnaire
c) 2 plastic zip-lock bags (OMEGA Bag 1 & OMEGA Bag 2)