8 Form

OMB#: 0925-0216

Exp. 12/2007        

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0216). Do not return the completed form to this address.

 

OMB#: 0925-0216

Exp. 12/2007  

Cardiac CT Scheduling Forms

The Framingham Heart Study Cardiac CT Scheduling Form

Participant Name: _____________________________

Phone Number: _______________________________

Your CT Scan has been scheduled at:

Mass General West Imaging Center

40 Second Ave.

The PARC Center

Suite 120

Waltham, MA 02451

Your appointment is scheduled for:

____________________________________________________

Please arrive 15 minutes before your scheduled appointment.

Enclosed are directions and map

Any questions or problems, please call Maureen Valintino at 508-935-3417 or 1-800-854-7582 x417.

The Framingham Heart Study

Pregnancy Determination Form

[Required for all Women]

FHS I.D. Number:

Last Name: First Name: Middle Name:

1. Are you Pregnant? � Yes ® Participant is disqualified from the study

• No

• Don’t Know

2. For women < 55 years old:

2.a Have you had a hysterectomy [removal of the uterus] or tubal ligation [tubes tied]?

• Yes ® Pregnancy test NOT required

• NO ® Pregnancy test REQUIRED

3. For women > 55 years old:

3.a Have you had a hysterectomy [removal of the uterus] or tubal ligation [tubes tied]?

• Yes ® Pregnancy test NOT required

• NO

¯

3.b When was your last menstrual period?

� > 6 months ago ® Pregnancy test NOT required

� Within 6 months ® Pregnancy test REQUIRED

4. Pregnancy Test Required? � Yes ® Result � Positive � Negative

� NO

5. Supplement to Pregnancy Form � Yes � No

6. Date of pregnancy interview and pregnancy test [if required]:

��/��/����

m m d d y y y y

7 . ID number of the person completing this form ����