Patients approached by facility staff for enrollment

Attachment 5 A 2

II. Patient Information

Date of Birth

Record the patients’ month, day, and year of birth in the appropriate spaces. The names of months should be converted to numeric representations and years should be recorded in full. Single digit months or days should be preceded by a zero.

For example, if the patient was born on February 15, 1960, the date of birth would be recorded as "02 / 15 / 1960."

Please Note: If any part of the date of birth is unknown, the space(s) corresponding to the missing information should contain a decimal point(s) and the patient's age should be recorded in the adjacent field.

Sex at Birth

Indicate the patient's sex at birth by checking the appropriate box (only one box should be checked).

Current Sex

Indicate the patient's current sex by checking the appropriate box (only one box should be checked). You many need to search in the medical record to see if there is a different sex (gender) reported by the patient or if there are indications that the patient is in the process of gender transformation such as treatment with hormones and scheduled surgery.

Hispanic or Latino Ethnicity

Indicate if the patient is Hispanic or Latino by checking the appropriate box.

Race

Indicate the patient's race by checking the appropriate box(es) (multiple boxes may be checked).

Most recent weight in lbs

Record the weight documented at the visit prior to the surveillance period or at the visit closest to the surveillance period. If multiple weight measurements are available record the latest available weight. If weight is given in kilograms (Kg) change this to lbs by multiplying by 2.2.Enter the date of this most recent weight if different from the visit prior to the surveillance period.

Height

Record the height in feet and inches. If there is more than one height documented, enter the most recent. Enter the date of this most recent height if different from the visit prior to the surveillance period.