2 survey

OMB# 0925-0491

EXPIRATION DATE XX/XXXX

CONFIDENTIAL DATA FORM

FORM CODE: C F D

VERSION C: 12/07/2006

ID NUMBER: CONTACT YEAR:

LAST NAME: INITIALS:

INSTRUCTIONS: For "multiple choice" and "yes/no" type questions, record the letter corresponding to the most appropriate response. If a letter is circled incorrectly, mark through it with an "X" and circle the correct response.

0. a. Hospital code number:

[If code 96-99, name and location]:

Hospital Name: ___________________________________

City and State: ___________________________________

0. b. Medical Record Number:

0. c. Date of discharge (for nonfatal case) or death:

Month Day Year

0. d. Has the hospital chart been located?

If No, go to Q6.

Yes……… Y

No………. N

1. a. Last Name:

b. First Name:

c. Middle Name:

2. Social Security Number:

 

2a. Medicare Number

3. Date of birth:

Month Day Year

4 . a. 0. Is this the patient’s address?........ Yes Y 4a. 1. Whose address

No N (relationship to patient)?

If Yes, skip to Question 4.b.1

4.b. Address Information

4. b. 1. PO Box, Box, &/or Route and Number:

4. b. 2. Street Number Prefix: 4. b. 3. Street Number: 4.b.4. Street Number Suffix:

4. b. 5. Street Name Prefix: 4. b. 6. Street Name (e.g., Elm): 4. b. 7. Street Name type:

4. b. 8. Street Name Suffix:

4. b. 9 Unit Type: 4. b. 10 Unit Prefix: 4. b. 11. Unit Identifier: 4. b. 12 Unit Suffix:

4.b.13 Other

4.c.1 City: 4.d.1 County: 4.e. State:

4.e.1 Country (if not USA): 4.f. Zip Code:

5. a. Cohort status:

ARIC Cohort ……………………………… …….. C

JHS Cohort-not ARIC Cohort………………….. J

Community , not in ARIC or JHS Cohort…….. S

2. Is the patient’s address in the ARIC community surveillance catchment area?

(Automatically filled by DES: Y if address is in catchment; else C if 5a=(C or J), O if (5a=S and out-

of catchment); else U if catchment area is unknown)

If Y,

C or O,

skip to Q6.

In catchment, needs abstraction ……………. …………………………… Y

Out of catchment, ARIC or JHS cohort, needs abstraction……………... C

Out of catchment, not in either ARIC or JHS cohort, do not abstract. . O

Undetermined by computer at this time …………………………………. U

c. Abstractor Investigation of Undetermined in Q5b. (If Q5.b = U then field center needs to work through all available resources or contact Coordinating Center to resolve whether patient’s address is in our out of catchment, then return to this form and fill out Q5.c. If finally the address cannot be resolved then “Undetermined” remains as a response below.)

In catchment, needs abstraction….. ……………………………………………… Y

Out of catchment, ARIC or JHS cohort, needs abstraction ..…………………... C

Out of catchment, not in either ARIC or JHS cohort, do not abstract……... . O

Undetermined after all means available to resolve, needs abstraction……… U

If O in 5c, document determination in notelog

ADMINISTRATIVE INFORMATION:

6 . Abstractor number:

7. Date abstract completed:

Month Day Year

CFDC Version C: 12/07/2007 4 of 5