SSA_Attachment 1_OS Data Collection Instrument List

ATTACHMENT 1

OS DATA COLLECTION
INSTRUMENTS

A summary of OS Participant data collection is included in the table below:
Form
#

Name

Change
since last
submission?

When administered

Oct2010

Oct2011

Oct2012

Sep2011

Sep2012

Sep2013

Yes,
combined w/
the former
F33D

X

X

X

33/33D

Medical History Update

No

X

20

Personal Information
Update (1st page only)

151

Activities of Daily Life

No

X

Medication and
Supplement Inventory

No

X

153

No

X

154

Breast Cancer Prevention
and Treatment
Medications*

155

Lifestyle Questionnaire

New

X

X

Face-to-Face Questionnaires (subsample; ~8000
women > age 80)
80

Physical Measurements

90

Functional Status

100

Blood Collection

Previously
approved
forms

X
X
X

*Form 154 administered only to women who report a breast cancer diagnosis

OBSERVATIONAL STUDY
PARTICIPANT QUESTIONNAIRES
Medical History Update (English)
(Spanish version currently being translated)
Personal Information Update
(Spanish version currently being translated)
Activities of Daily Life (English)
Activities of Daily Life (Spanish)
Medication and Supplement Inventory (English)
(Spanish version currently being translated)
Breast Cancer Prevention and Treatment Medications (English)
(Spanish version currently being translated)
Lifestyle Questionnaire (English)
(Spanish version currently being translated)
Physical Measurements (English)
(Spanish translation not required; interviewer-administered form)
Functional Status (English)
(Spanish translation not required; interviewer-administered form)
Blood Collection (English)
(Spanish translation not required; interviewer-administered form)