Form 1 Annual Study Update (ASU)

Version Date: 5/2008 Expiration Date: xx/xx/xxxx OMB#: 0925-0407

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including 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 Office, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.

ANNUAL STUDY UPDATE (ASU)
Participant ID: «9» «11» February 4, 2021 Participant Name: «10» «12» Study Year: «13» If Your Name (Printed Above) Is Incorrect, Please Record Your Corrected Name Below. Corrected Name: ____________________________________
In the period from «14» to the present, have you been diagnosed with cancer by a health care provider? (Do not include basal-cell or squamous-cell skin cancers.) Yes [ ] No [ ] (If no, men go to item 3; women go to item 4)
2. What type of cancer was diagnosed? (Please record all cancers diagnosed during this period except basal-cell and squamous-cell skin cancers.)
Type/Site of Cancer (breast, lung, etc)	Date of Diagnosis _____/______/____ _____/______/____ _____/______/____	Hospital or clinic where the cancer was diagnosed
What is the name, phone number and address of the physician who diagnosed the most recent cancer? Name:______________________________________ Phone: (____)_______________________ Address:________________________________________________________________________
3. FOR MEN ONLY: In the period from «15» to the present, have you taken the medication Proscar or Propecia (Finasteride)? Yes [ ] No [ ]
4. Today’s Date: ______/_______/______ Month Day Year 5. Who completed this questionnaire? (Please check one) [ ] Study Participant [ ] Spouse [ ] Someone else (SPECIFY)_______________________ Relationship
6. Comments: ___________________________________________________________________________________ _________________________________________________________________________________________

Thank you for completing this questionnaire. Please return this form in the enclosed envelope.

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

Participant ID Label

OMB #: 0925-0407 Exp. Date: xx/xx/xxxx Version Date: 10/96 *FLF* FLF

FOLLOW-UP LOCATOR FORM

Today's Date: |___|___| / |___|___| / |___|___|___|___|

^{MONTH DAY YEAR}

1.	What is your full name?
TITLE FIRST MIDDLE LAST SUFFIX

2.	Are you known by any other last name (please include your maiden name and any previous married names)?
MAIDEN NAME OTHER LAST NAME

3.	What is your date of birth?
|___|___| / |___|___| / |___|___|___|___| MONTH DAY YEAR

4.

What is your Social Security Number?

The National Institutes of Health is requesting your Social Security Number under Public Health Service Act 42 USC 285a. The primary use of this information is for researchers to locate you in the future if they are unable to locate you at your home address, and to search vital records in a followup study conducted in the future. Additional disclosures of information may be: to HHS contractors, grantees, and collaborating researchers and their staff in order to accomplish the research purpose for which the records are collected; to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of the individual; and as otherwise required by Law. Furnishing your Social Security Number is voluntary, and you will not be denied any federal right, benefit, or privilege by your refusal to disclose it. |___|___|___| - |___|___| - |___|___|___|___|

5.	What is your current primary home address and telephone number?
STREET ADDRESS APT. NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )
6.	What is your work telephone number? (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 7)
TELEPHONE NUMBER: (              )

(OVER)

7.	If you have a vacation home or other residence, what is that address, telephone number and time of year of residence? (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 8)
STREET ADDRESS APT. NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )		MONTHS OF YEAR SPENT AT OTHER RESIDENCE (RECORD EXACT DATES IF POSSIBLE) FROM: TO:

8.	Please list the names of two adults who live in your household and their relationship to you. (Include your spouse, partner, children, relatives, and/or roommates.) (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 9)
FULL NAME OF HOUSEHOLD MEMBER RELATIONSHIP TO PARTICIPANT 1.
2.

9.	What is the name, address, and telephone number of your current primary care physician or clinic? (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 10)
FULL NAME OF PHYSICIAN OR CLINIC
STREET ADDRESS: SUITE OR OFFICE NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )

10.	It would be of great help to us if you could provide us with the names and addresses of two people who could give us your new address should you move. We would only contact these people if we were unable to reach you at your home address. It would be helpful to get the names of people who do not live with you.
FULL NAME 1.		RELATIONSHIP TO YOU
STREET ADDRESS		TELEPHONE NUMBER (              )
CITY STATE ZIP
FULL NAME 2.		RELATIONSHIP TO YOU
STREET ADDRESS		TELEPHONE NUMBER (              )
CITY STATE ZIP