Form 1 Telephone Screener

Patient ID __ - __ - __ __ __ __ __ __

Subject

OMB# 0925-XXXX

Expiration Date: XX / XX / XXXX

Attachment # 16: Telephone Screener for Population Controls

________________________________________________________________________

BURDEN STATEMENT:

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-xxxx) Do not return the completed form to this address.

PRIVACY STATEMENT:

Statement Of Privacy Act Applicability

You will be asked to participate in the research study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700”. The study will collect and use health information that can identify you. The authority to collect this information is under 42 USC 285 for the National Cancer Institute, National Institutes of Health. The Privacy Act from 1974 applies to the information collection.

Federal laws require researchers to protect the privacy of your health information. The collection of health information by this study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700” is covered by the Privacy Act and is in compliance with the Privacy Act System of Records Notice (SORN) # 09-25-0200 http://oma.od.nih.gov/ms/privacy/pa-files /0200, which covers clinical, basic, and population-based research studies of the National Cancer Institute and the National Institutes of Health.

Subject

LHC University of Maryland Case-Control Studies

Population Controls:

Screening Form (completed electronically through the database)

A. Demographics

1. Subject’s Name:_____________________________

B. Eligibility Criteria:

1. Were you born in the United States?	( ) Yes	( ) No
2. What do you consider yourself?
Black or African American? White or Caucasian? (LIVER STUDY ONLY) Asian? (LIVER STUDY ONLY) Native Hawaiian or Other Pacific Islander? (LIVER STUDY ONLY) American Indian or Alaska Native? (LIVER STUDY ONLY) Other –Specify___________________	( ) Yes ( ) Yes ( ) Yes ( ) Yes ( ) Yes	( ) No ( ) No ( ) No ( ) No ( ) No
3. Are you 40 years old or older?	( ) Yes	( ) No
4. Are you residing in an institution such as a shelter, nursing home or prison?	( ) Yes	( ) No
5. Do you have a physical Impairment that makes you unable to participate in an interview? If yes, what kind? _____________________________________________	( ) Yes	( ) No
6. Have you ever had cancer? If yes, what kind?______________________________	( ) Yes	( ) No
7. Have you been diagnosis with HIV, hepatitis B or C? ( )1 Yes ( )0 No Check all that apply ( ) 1 HEP B ( ) 2 HEP C ( ) 3 HIV
8. Does the patient speak English well enough to be interviewed?	( ) Yes	( ) No
9. Does the respondent hear well enough to be interviewed?	( ) Yes	( ) No
10. The respondent is mentally stable?	( ) Yes	( ) No
11. Have you ever had radiation or chemotherapy? ( )1 Yes ( )0 No
12. Have you had surgery with anesthesia in the last two months? ( )1 Yes ( )0 No
13. Have you taken steroids or immunosuppressants in the last three months? ( )1 Yes ( )0 No
14. Are you currently taking antibiotics? ( )1 Yes ( )0 No

C. Administrative Information completed in the computer data base.

( )₁ Yes ( )₀ No Eligible

MLCS Page 2

Population control screener 1.4 5/6/2010