Form 1 survey

Appendix 3: Cohort and Community Surveillance
Coroner/Medical Examiner Form ................................................................................. 1
Informant Interview Form ............................................................................................. 9
Physician Heart Failure Form ...................................................................................... 20
Physician Questionnaire Form ..................................................................................... 22

O. M. B. 0925-0281
Exp. XX/XXXX

ARIC
Atherosclerosis Risk in Communities
EVENT ID:

CORONER / MEDICAL EXAMINER
FORM
C

FORM CODE:

LAST NAME:

O

R

VERSION: C

DATE: 05/22/07

INITIALS:

Public reporting burden for this collection of information is estimated to average 6-15 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 (0925-0281). Do not return the completed form
to this address.

INSTRUCTIONS: The Coroner/Medical Examiner Form is completed for each eligible out-of-hospital death that was identified as a coroner or medical examiner case
on the death certificate, and recorded as such on the Death Certificate Form. Event ID, Name (or Soundex code) must be entered above. Refer to this form's Q x Q
instructions for information on specific items. For multiple choice and "yes/no" questions, circle 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.

CORONER/MEDICAL EXAMINER FORM (CORC Screen 1 of 13)
4.

1. Date of death from death certificate:

Has an official coroner's or medical
examiner's report or another source
of information from the coroner's or

Month

Day

Year

medical examiner's office been located?
Yes ................ Y

2. Is the name of coroner's or medical examiner's office available?

No ................ N

Yes ............. Y

Go to Item 25,
Screen 13.

No ..…....... N
5.
If "Yes", Specify: ______________________________________

Was an autopsy performed as part of
the medical examiner (coroner)
investigation?
Yes .............. Y

3. Abstracting for:
Cohort ...........….. C
Surveillance ........ S

No .............. N

1

CORONER/MEDICAL EXAMINER FORM (CORC Screen 2 of 13)
6.

Did the coroner's report mention any
of the following as contributing to or
being present at death?

6.f.
Yes

No

a. Recent myocardial infarction ...........…………… Y

N

b. Coronary heart
disease/ischemic/atherosclerotic
heart disease (other than MI) .……………........ Y

N

c. Hypertensive heart disease .........………….……. Y

N

d. Valvular heart disease ...…………………........... Y

N

e. Other heart disease ……………………………... Y

N

Yes No
Recent cerebral
hemorrhage .........……..………………... Y
N
g. Recent cerebral
infarction ........………………….……... Y

N

h. Recent cerebral
embolus ........………………….……..... Y

N

i. Recent subarachnoid
hemorrhage .........……………..……….. Y

N

j. Recent stroke, other
or unspecified type .…………………….... Y

N

CORONER/MEDICAL EXAMINER FORM (CORC Screen 3 of 13)
7.a.

Was any non-cardiac, non-stroke
finding mentioned as contributing
to death?

Yes
7.e. Alcohol or drug
addiction ......……………..

Yes ......... Y
No .......... N
Go to Item 8,
Screen 4

Yes

No

Y

N

f. Epilepsy .........…………….. Y

N

g. Liver disease ....…………... Y

N

h. Other ......….....……….…... Y

N

No

b. Kidney disease ...…………………. Y

N

c. Chronic respiratory disease ............ Y
d. Psychiatric illness/depression .......... Y

N
N

If Other is Yes, Specify:
_______________________________
_______________________________
_______________________________

2

CORONER/MEDICAL EXAMINER FORM (CORC Screen 4 of 13)
ID LABEL

8. Do you have the final diagnoses?
┌────────────────────────────────────────────────────────── Yes
│
│
No
└── Specify:

Y
N

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

3

CORONER/MEDICAL EXAMINER FORM (CORC Screen 5 of 13)
9. Pick one of the
following (A,B*,C*,D*,U*):

Patient died suddenly and was
known to have no acute symptoms ....… B

Patient had acute symptoms (cardiac
or non-cardiac) which led to an overt
change in activity or to seeking medical care....……….. A

Patient was found dead with no
documentation of symptoms .......…… C

Patient had symptoms but they were
chronic (without change) or did
not lead to a change in activity
or seeking medical care ..........……… D

Unknown ...........................…………. U
Go to Item 11.a,
Screen 7.

CORONER/MEDICAL EXAMINER FORM (CORC Screen 6 of 13)
Yes No Unknown
10.g. Paralysis ....……. Y N
U

10. Within 3 days of death or just
before death, did any of the
following symptoms begin for
the first time?
Yes No Unknown
a. Shortness of breath .......... Y N
U
b. Dizziness.…………......... Y

N

U

c. Palpitations .…………... Y

N

U

d. Marked or increased
fatigue, tiredness
or weakness ..…………. Y

N

U

e. Headache ......………... Y

N

U

f. Sweating ....…………... Y

N

U

h. Loss of speech ….. Y

N

U

i. Attack of
indigestion
or nausea or
vomiting......…….... Y

N

U

j. Other .........……….. Y

N

U

If other is Yes, Specify:
______________________________
_______________________________

4

CORONER/MEDICAL EXAMINER FORM (CORC Screen 7 of 13)
11.a. Was there an acute episode(s)
11.c. Did the patient take or
of pain or discomfort anywhere
was he/she given nitrates
in the chest, left arm or
shoulder or jaw either just
at the time of the acute
before death or within
episode?
72 hours of death?
Yes ......…….... Y

Yes ……....... Y

No .........……. N

No .……....... N

Unknown ....... U

Unknown ..... U

Go to Item 12
Screen 8.

d. Was the discomfort or
pain diagnosed as
having a non-cardiac
origin?

b. Did this pain or discomfort
specifically involve the chest?

Yes ....……... Y
Yes ...……....... Y
No .....……... N
No ….............. N
Unknown ..... U
Unknown ........ U
If "Yes", Specify:
___________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 8 of 13)
13.a. Did anyone witness the death?
Yes ..........…………. Y

12. Place of death (circle only one):
Home (or other private
residence) ......…......……...

A

No .........…………... N

Work .................…………...

B

Unknown .…………. U

In a public building .....……. C

Go to Item 15a
Screen 10.

On a bus or public
transportation ....….....……. D
b. Do you have the name and
address for this witness?

On the street .......…....……

E

In an automobile .........……

F

Yes ............ Y

In nursing home ..........……

G

No .............. N

In emergency room ....…….

H

If "Yes", Specify:

In an ambulance .........…….

I

Name:

In hospital ..........…....…….

J

Address: _______________________________

Other ....................………

O

_______________________________

Unknown .................……..

U
5

_________________________________

CORONER/MEDICAL EXAMINER FORM (CORC Screen 9 of 13)
13.c. Relationship of this witness to
deceased:

14. Time from onset of acute
symptoms to death (or time
since last known to be

Spouse .........…...... S

alive if no known acute
Parent ...........……. P

symptoms) (Choose only one):

Daughter/Son ........ C
5 minutes or less ......………….... A
Other Relative ...... R
More than 5 minutes
to 1 hour ……………………...... B

Friend ............…… F

More than 1 hour
to 24 hours ....….……………...... C

Workmate ............ W
Other .............…... O

More than 24 hours ....………...... D
Unknown ............. U
Unknown ..........……………........ U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 10 of 13)
15.a. Is there a history of a myocardial
infarction prior to the onset of
this event?

15.c. Was the deceased hospitalized
for the MI?
Yes .......………... Y

Yes .........……... Y
No ..........…….… N
No .............…… N
Unknown ..…...... U
Unknown .......... U

Go to Item 16
Screen 11.

Go to Item 16
Screen 11.

d. Do you know the name of the
hospital?

b. Did an MI occur within four weeks
prior to this event?

Yes .....…….….... Y

Yes .............. Y

No ......………..... N

No .............……………….. N

If "Yes", Specify:

Unknown ……………….... U

_____________________________________

Go to Item 16
Screen 11.

6

CORONER/MEDICAL EXAMINER FORM (CORC Screen 11 of 13)
16. Is there any history of angina pectoris

18. Is there a history of valvular disease
or cardiomyopathy?

or coronary insufficiency?

Yes ..……............ Y

Yes .............……... Y

..

No ..........……...... N

No .…….............. N

Unknown ............. U

Unknown ............ U

19. Is there a history of coronary bypass
surgery prior to this event?

17. Is there a history of any other chronic
ischemic heart disease?
Yes ..........……...... Y

Yes .........…........ Y

No ...........……...... N

No ....……........... N

Unknown .............. U

Unknown ............ U

CORONER/MEDICAL EXAMINER FORM (CORC Screen 12 of 13)
20. Is there a history of coronary

22. Is there a history of hypertension
(high blood pressure) prior to this
event?

angioplasty prior to this event?
Yes ..........…....... Y

Yes ...……...... Y

No ............……... N

No .……......... N

Unknown ............ U

Unknown ....... U

21.a. Is there a history of stroke
prior to this event?

a. Is there a history
of diabetes?

Yes ............…….. Y

Yes ........…… Y

No ..........……..... N

No ........….…. N

Unknown ............ U

Unknown ....... U

Go to Item 22

b. Is there a history
of smoking?

b. Did a stroke occur within four
weeks prior to this event?

Yes .....……... Y

Yes ....……....... Y

No .....…….... N

No .......……..... N

Unknown ...... U

Unknown ......... U

7

CORONER/MEDICAL EXAMINER FORM (CORC Screen 13 of 13)
23. Was the decedent taking any of the
following medications as an outpatient
within the four weeks prior to death?

24. Was this form completed by abstraction
or by interview with the coroner?

Yes No Unknown
a. Nitrates ...……..... Y

N

U

b. Calcium channel
blockers ....……... Y N

U

c. Beta-blockers ….. Y

N

U

d. Digitalis .....……. Y

N

U

Abstraction .............. A
Interview ..…............ I

25. Abstractor Number:

e. ACE or angiotensin II
inhibitors ... ……… Y
f. Aspirin .......……. Y

N
N

26. Date abstract completed:

U

Month

U

8

Day

Year

O. M. B. 0925-0281
Exp. XX/XXXX

ARIC

INFORMANT INTERVIEW FORM

Atherosclerosis Risk in Communities

EVENT ID:

SEQUENCE NUMBER:

LAST NAME:

FORM CODE:

I

F

I

VERSION: C DATE: 05/23/2007

INITIALS:

Public reporting burden for this collection of information is estimated to average 6-15 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 (0925-0281). Do not return the completed form
to this address.

INSTRUCTIONS: The Informant Interview Form is completed for each informant for an out-of-hospital death as determined by the ARIC Event Investigation
Summary. Event ID and Name must be entered above, as described in the document, "General Instructions For Completing Paper Forms". Informant Number
should be determined from the Event Investigation Summary Form. For "multiple choice" and "yes/no" type questions, circle the letter corresponding to the most
appropriate response. If a letter is circle incorrectly, mark through it with an "X" and circle the correct response.

INFORMANT INTERVIEW TRACING INFORMATION
Name:

DECEDENT
________________________________________________________________________________

Address: ________________________________________________________________________________
________________________________________________________________________________
________________________________________________ _____________ ________________
City
State
Zip Code
Date of death: / /
Age: ______ years
mm dd yyyy
Place of death: ___________________________________________________________________________
INFORMANT
Name:

________________________________________________________________________________

Address: ________________________________________________________________________________
________________________________________________________________________________
________________________________________________ _____________ ________________
City
State
Zip Code
Telephone: ( _ )

_- ______

Relationship to the deceased: ________________________________________________________________
9

RECORD OF CALLS
Day of Week

Date

SMTWRFS

MM/DD/YYY

Time

Notes

Code*

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

SMTWRFS

MM/DD/YYY

A
P

* RESULT CODES (CIRCLE THE FINAL SCREENING RESULT CODE)
1
2
3
4

Complete
Partially complete
Unknowledgable
Refusal

5
6
7
9
10

Informant away or can't be found
Language barrier
No one home
Other (specify in Notes)

Int

INFORMANT INTERVIEW FORM (IFIC Screen 1 of 16)
"I'd like to ask you about (
)'s medical
history. If you have any questions as we go along,
please ask me."

A. HISTORY
1. Before we get started could you please tell me
what was your relationship to the deceased?

2. First, think back to about one month before (
died. At that time, was he/she sick or ill,
with his/her activities limited, or was he/she
normally active for the most part?

{Respondent was deceased's}
Spouse .....…… S

)

Parent ...…...... P
Sick/ill/limited activities .... R
Daughter/Son ... C
Normally Active ................ N
Other relative .. R
Unknown ..................….... U
Friend .…........ F
Workmate ...... W
Other .…......... O

INFORMANT INTERVIEW FORM (IFIC Screen 2 of 16)
3. Was (
) being cared for at a nursing
home, or at another place at the time of death?

5. Was (
) hospitalized
within the four weeks prior
to death?

Yes, nursing home ......…. R

Yes ....... Y

Yes, at home ...........……. H
Go to Item 9,
Screen 3

Yes, assisted living ..…..... A

Unknown ... U

Yes, Hospice facility ..…. F
Go to Item 5

Yes, other .............……... O

6. What was the reason for hospitalization?

No ....................……….... N

{Circle (Y), (N), or (U) for each. Probe if not
offered.}

Unknown .............…….... U
4. Could you tell me the name and
location of the nursing home?
Specify Name, City, State

Yes ...... Y

Skip Name, City, State

No ....... N

No ........ N

If no or
unknown, go
to Item 9,
Screen 3

[Place Name, City, State in notelog]
Name _____________________________
_____________________________
City _____________________________
State _____________________________
11

Yes No Unknown
a. Heart attack
or chest pain

Y

N

U

b. Heart surgery

Y

N

U

c. Other

Y

N

U

INFORMANT INTERVIEW FORM (IFIC Screen 3 of 16)
7. What was the date of the hospital admission?

Month

Day

10. Could you tell me the name
and address of this physician?

Year

8. Could you tell me the name
and location of the hospital?

Specify Name, City, State

Yes ...... Y

Skip Name, City, State

No ....... N

Specify Name, City, State

Yes .….. Y

[Place Name, City, State in notelog]

Skip Name, City, State

No ..…... N

Name _____________________________
_____________________________

[Place Name, City, State in notelog]

City _____________________________

Name ____________________________

State _____________________________

____________________________
11. Could you tell me the name
and address of (
)'s
usual physician? (If same as
Q10 record as "same.")

City ____________________________
State ____________________________

9. Was (
) seen by a physician anytime
in the last four weeks prior to death?
Yes ....……. Y

Specify Name, City, State

Yes ...... Y

Skip Name, City, State

No ....... N

[Place Name, City, State in notelog]

No ......…… N

Name ______________________________

Unknown ... U

______________________________

Go to Item 11

City ______________________________
State ______________________________

12. Before (
) 's final illness,
had he/she ever had pains in the chest
from heart disease, for example angina
pectoris?
Yes ..……... Y
Go to Item 14,
Screen 4

No ...……... N
Unknown ... U

12

INFORMANT INTERVIEW FORM (IFIC Screen 4 of 16)
13. Did (
) ever take
nitroglycerin for this pain?

15. Was (
) hospitalized
for a heart attack?

Yes ...…….. Y

Yes ...…..... Y

No ....…….. N

No ....…….. N

Unknown ... U

Unknown ... U

14. Did a doctor ever say that
(
) had a heart
attack prior to his/her
final illness?

16. Did he/she ever have a coronary bypass operation,
balloon angioplasty or some other operation or
procedure to improve the circulation of blood to
the heart?
Yes ....….... Y
Yes ...…….. Y
No ......……. N

Go to Item 16

No ....…….. N
Unknown ... U
Unknown ... U

INFORMANT INTERVIEW FORM (IFIC Screen 5 of 16)
17. Did (
) ever have any other heart disease or
condition before his/her final illness?

heart

19.a. Did he/she have a stroke within
four weeks of his/her final illness?

┌────────Yes .....….. Y
│
│
No .....……. N
│
│
Unknown ... U
│
└──If yes, specify: _______________________________

Yes .....…… Y
No .....……. N
Unknown ... U

b. Did he/she have a history of cigarette smoking?
___________________________________________
Yes .....…… Y
___________________________________________
No ......…… N
18. Did (

) ever have a stroke?

Unknown ... U

Yes ....…... Y
No .....…... N

c. Did he/she have a history of diabetes?

Go to Item 19b
Unknown ... U

Yes ...…….. Y
No ....…….. N
Unknown ... U

13

INFORMANT INTERVIEW FORM (IFIC Screen 6 of 16)
B. CIRCUMSTANCES SURROUNDING DEATH
Attach Event ID Label Here

"The next few questions are concerned with the circumstances surrounding (

20. Could you please tell me what you can of (
itself?

)'s death."

)'s general health, on the day he/she died, and of the death

┌───────Yes ..…….. Y
│
│
No .....…… N
│
│
Unknown ... U
│
│
└───────Specify: _______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
14

INFORMANT INTERVIEW FORM (IFIC Screen 7 of 16)
23. Was anyone close enough to hear (
if he/she had called out?

"The next set of questions may go over some of what you have
already told me. Although it may seem repetitious, I must
ask these questions for consistency of information."
21. Were you present when (

Go to Item 25,
Screen 8

) died?

)

Yes ....... Y
No ........ N

Go to Item 25,
Screen 8

Yes ....... Y
Unknown ... U
No ……. N

22. Did anyone see or hear (
Go to Item 25,
Screen 8

) when he/she died?
24. How long after (
) was last
known to be alive was he/she found dead?

Yes ..……... Y

{Enter the shortest interval known to be true}

No .....……. N

5 minutes or less .…... A

Unknown ... U

1 hour or less .....…..

B

24 hours or less ...….. C
More than 24 hours .... D
Unknown ............…... U

INFORMANT INTERVIEW FORM (IFIC Screen 8 of 16)
25. Where was (

) when he/she died?

C. SYMPTOMS

Home (or other private residence) ........ A

"The next few questions are concerned
with any symptoms (
) may
have had shortly before he/she died."

Work .................................…………... B
In a public building .................………. C

26. Did (
) experience pain or
discomfort in his/her chest, left
arm, or shoulder or jaw either
just before death or within 3 days
(72 hours) of death?

On a bus or public transportation .….... D
On the street .........................………… E
In an automobile ...................………... F

Yes ...…….. Y
In a nursing home ..................……..... G
Go
GototoItem
Item30,
30,
Screen
10
Screen 10

In an emergency room ...............…..... H
In an ambulance ...................……….... I
In the hospital ......................…………. J
Other ..............................…………..... O
Unknown ........................………......... U

15

No ....……. N
Unknown ... U

INFORMANT INTERVIEW FORM (IFIC Screen 9 of 16)
"The next set of questions deal specifically with the last
episode of (
)'s pain or discomfort. The last
episode is defined as starting at the time (
)
noticed discomfort that caused him/her to stop or change
what he/she was doing."

28. Did he/she take nitroglycerin
because of this last episode
of pain or discomfort?
Yes .....…… Y

27. Did (
)'s last episode of pain or
discomfort specifically involve the chest?

No ......…… N
Unknown ... U

Yes ...…….. Y
No .....……. N
Unknown ... U

INFORMANT INTERVIEW FORM (IFIC Screen 10 of 16)
29. How long was it from the beginning
of (
)'s last episode of
pain or discomfort to the time he/she
stopped breathing on his/her own?

30. Within 3 days of death or just
before (
) died, did
any of the following symptoms
begin for the first time?

{Circle the shortest interval known to be true}

{Circle (Y), (N) or (U) for each}
Yes

No

Unknown

a. Shortness of breath

Y

N

U

C

b. Dizziness

Y

N

U

24 hours or less ........…….

D

c. Palpitations (pounding
in the chest)

Y

N

U

More than 24 hours ......….

E
N

U

U

d. Marked or increased
fatigue,tiredness, or
weakness

Y

Unknown .............……......

e. Headache

Y

N

U

f. Sweating

Y

N

U

g. Paralysis

Y

N

U

h. Loss of speech

Y

N

U

i. Attack of indigestion
or nausea or vomiting

Y

N

U

j. Other

Y

N

U

5 minutes or less .....……...

A

10 minutes or less .....…….

B

1 hour or less .........………

If Other, specify:_________________________________
_______________________________________________
_______________________________________________
16

INFORMANT INTERVIEW FORM (IFIC Screen 11 of 16)
31. Was a physician, ambulance, or
other emergency medical team called?

D. EMERGENCY MEDICAL CARE

" The next few questions are concerned with emergency
medical care (
) may have received prior
to or at the time of death. You may have already
given this information in an answer to an earlier
question. Since it is important to obtain information
specifically on emergency medical care, I hope you
don't mind if these questions seem repetitive."

Yes ....…… . Y
No .....……. N
Go to Item 35,
Screen 13

Unknown ... U

32. Was (the physician, ambulance,
or EMS team) called because of
symptoms (
) was having
or after he/she was already dead?
Symptoms ....... S
Go to Item 35,
Screen 13

Already Dead ... D

INFORMANT INTERVIEW FORM (IFIC Screen 12 of 16)
33. How long was it from the time
the last episode of symptoms
started to the time that medical
assistance was called for?

34. How long was it from the time
that medical care was called
to the time when it arrived?
{Circle the shortest interval known to be true}

{Circle the shortest interval known to be true}
5 minutes or less .....…… A
5 minutes or less ....…. A
10 minutes or less .....….. B
10 minutes or less ...... B
1 hour or less ........…….. C
1 hour or less .......….. C
6 hours or less ........……. D
6 hours or less .....….. D
24 hours or less .......…… E
24 hours or less ...….. E
More than 24 hours .....… F
More than 24 hours .... F
Unknown ................…… U
Unknown ..............…. U
Did not come ..........…… X

17

INFORMANT INTERVIEW FORM (IFIC Screen 13 of 16)
35. Were resuscitation measures, such as closed chest
massage or CPR, attempted at the time?

37. Where was resuscitation or CPR started?
Home (or other

Yes ...…….. Y

private residence) ...........… A

No ...…..…. N
Go to Item
38,

Work .........................…….. B

Unknown .... U

Public place ................…… C
Ambulance or

36. Who started the resuscitation or CPR?

other emergency vehicle .... D
Bystander, non-health professional ..... A
Go to Item
39,
Screen 14

M.D. .......................…………….......... B
Ambulance attendant, paramedic,

Emergency room ................. E
Hospital ......……................. F
Other ....................……........ O

or other health professional ..……...... C

Unknown .......................…. U

Fireman or policeman .……................. D
Other ...........................……………..... O
Unknown .............................………… U
INFORMANT INTERVIEW FORM (IFIC Screen 14 of 16)
38. Was (

) taken to a hospital?

E. ADDITIONAL INFORMATION

Yes ....…….. Y

40. Is there someone else whom we
could contact, who might know
more about the circumstances
surrounding (
)'s death
or his/her usual state of health?

No ......……. N
Go to Item 40
Unknown .... U

Yes ....……. Y
39. Could you tell me the name
and location of this hospital?
Specify Name, City, State

Yes ...... Y

Skip Name, City, State

No ....... N

Read "final script"
then go to Item 43,
Screen 15

No ......…… N
Unknown .... U

41. Could you tell me the name, address,
and telephone number of this person?

[Place Name, City, State in notelog]
Name _______________________________

Specify Name, City, State, Phone

Yes .... Y

Skip Name, City, State, Phone

No ..... N

City

__________________________

[Place Name, City, State, Phone in notelog]

State

__________________________

Name ___________________________________
City

___________________________________

State

___________________________________

Phone ___________________________________

18

INFORMANT INTERVIEW FORM (IFIC Screen 15 of 16)
42. How was he/she related to the deceased?

F. RELIABILITY

Spouse ..........…… S

{To be completed immediately after the interview}

Parent ..........……. P
Daughter/Son .….. C
Other relative …... R

43. Did the respondent frequently
contradict himself/herself or
give information that he/she
would have no way of knowing? ...... Yes

Y

No

N

Friend ..........……. F
Workmate .....…... W
Other ..........…….. O
[Read "final script",then go to Item 43]

44. Did the respondent seem to
be reluctant to answer questions
and thus might not have given all
the information the interviewer
would wish to know? ................. Yes

Y

No

N

INFORMANT INTERVIEW FORM (IFIC Screen 16 of 16)
45. On the basis of these
questions, give your
rating of reliability
of the interview. ......... Good

G. ADMINISTRATIVE INFORMATION
G
48. Date of data collection:

Fair

F

Poor

P
Month

46. Would you like to add
other details concerning
the quality of the interview?

Day

49. Method of data collection:
Yes ....... Y

Computer ....... C

No ........ N

Paper Form ..... P

If Yes, specify: ____________________________
_________________________________________

50. Code number of the person
completing this form. ....…..

_________________________________________
47. Informant agreed to provide
consent to gather further
information?

51. Result Code:
Yes ............…… Y
No ............…….. N
Not applicable ... A

If Yes, specify _________________________________
______________________________________________
______________________________________________

19

Year

FORM CODE: PHF

Version: A

06/05/07

ARIC ID: CY: < 00 > SEQ: <00>

ARIC Heart Failure Survey
Dear < Dr

O.M.B 0925-0281
Exp. XX/XXXX

>,

Your patient, <
Ms/Mr.
> who is a long time participant in the ARIC Study, has
indicated to ARIC study personnel that < s/he > has been diagnosed with heart failure. We have your
patient’s authorization to ask you to provide this information for our study records. We appreciate your
response to the following questions and request that you return this form in the enclosed envelope at
your earliest convenience (ideally within 2 weeks).
Thank you.
Sincerely,
<
Field center medical director

>

Date <

Patient Name < Ms/Mr.

>

Date letter is sent >

Patient Date of Birth < mm/dd/yyyy >

1. Has this patient ever had heart failure or cardiomyopathy of any type?  Yes  Unsure  No

(If response is NO, skip to question 3)

2. If the patient has or ever had heart failure or cardiomyopathy:
(a) Is this patient’s condition characterized as predominantly:
 Systolic dysfunction  Diastolic dysfunction  Mixed  Not determined
(b) Estimated LVEF (worst): ____%
(b.1.) If LVEF is not specifically available, estimate LV function:
 Normal
 Decreased mildly  Decreased moderately  Decreased severely
(c) Estimated date of onset or diagnosis: ___ / _______ (month/year)
3. Has this patient ever had (check all that apply):
 Atrial fibrillation on an ECG?
 Pulmonary rales on a physical examination?
 Rhonchi on a physical examination?

 Angina pectoris?
 Previous MI?
 Other coronary heart disease?
 None of the above
4. Was s/he prescribed treatment specifically for heart failure during the past year?
 Yes
 No
 Not known
5. Was this patient prescribed any of the following during the past year? (check all that apply)
 ACE inhibitors
 Beta blockers
 Alpha blockers
 Calcium channel blockers
 Aldosterone blocker
 Digitalis
 Amiodarone / Antiarrhythmics
 Diuretics
 Angiotensin II receptor blockers
 Hydralazine
 Anticoagulants
 Lipid-lowering agents
 Aspirin / Antiplatelets
 Nitrates
 Other antihypertensives
Form completed by:

Date:

___________________________

_______________________

(Signature or stamp )

(MM/ DD /YY)

20

ARIC Heart Failure Survey

O.M.B 0925-0281
Exp. 05/31/2010

Public reporting burden for this collection of information is estimated to average 4 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 208927974, ATTN: PRA (0925-0281). Do not return the completed form to this address.

21

O. M. B. 0925-0281
Exp. XX/XXXX

ARIC

Atherosclerosis Risk in Communities

PHYSICIAN QUESTIONNAIRE
FORM

Public reporting burden for this collection of information is estimated to average 6-15 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 (0925-0281). Do not return the completed form
to this address.

ARIC Center use only

Version C: 05/22/07

Decedent's Name: _________________________________ Age: ____ Date of Birth: ___/___/_____ Date of Death: ___/___/_____
EVENT ID:

Sequence Number:

Physician's Name _____________________________

Please complete the following and return in the enclosed envelope.
A. MEDICAL HISTORY
1. Are you familiar with the decedent's medical history?
Yes

No
If No, skip to Item 5 on Page 3.

2. When did you last see the decedent? .....
Month

Year

3. Did the decedent have a history of any of the following?
Yes

No

Uncertain

a. Angina pectoris or coronary insufficiency ...
b. Valvular disease or cardiomyopathy ..........
c. Coronary bypass surgery ………………….
d. Coronary angioplasty ......................……….
e. Hypertension ............................……………
f. Myocardial infarction .....................………..
┌────────────────────────────────
│
g. If MI Yes, date of most recent event:
Month

Year

22

3. (cont'd) Did the decedent have a history of any of the following?
Yes

No

Uncertain

h. Other chronic ischemic heart disease:….
i. Stroke (CVA):…………………………

j. If Yes, date of most recent event:
Month

Year

k. Any non-cardiac condition that might Yes
No
Uncertain
have contributed to this death:
┌────────────────────────┘
│
└─ If Yes, specify: ______________________________________
Yes

No

Uncertain

l. Diabetes: ......................…………….
m. Cigarette smoking: .............………
4. Was the decedent taking any of the following medications
within four weeks prior to death?
Yes

No

Uncertain

a. Nitrates .................………….
b. Calcium channel blockers …..
c. Digitalis ................…………..
d. Beta-blockers ............………
d.1. Aspirin .............………….
d.2. ACE or Angiotensin II
inhibitors .....……..
e. Other cardiovascular drugs
┌──────────────────┘
└─ If Yes, specify: _______________________________________

23

B. DETAILS OF DEATH
5. Are you familiar with the events surrounding the decedent's death?
Yes

No

6. Did you witness the death?
Yes

If you answered No to both 5 & 6,
skip to Item 14 on page 4.
Otherwise, continue with Item 7.

No

7.a. Was there any pain in the chest, left arm or shoulder or jaw
within 72 hours of death?
Yes

No

Uncertain
If No or Uncertain, skip to item 8

b. Did the pain include the chest?
Yes

No

Uncertain

c. Did you think this pain was of a cardiac origin?
Yes

No

Uncertain

If No, specify what you think was the cause:
__________________________________________
8. Did the decedent take (or was he/she given) nitrates
at the time of the acute episode?
Yes

No

Uncertain

9. Was coronary reperfusion (intravenous or intracoronary streptokinase or
TPA, angioplasty, etc.) attempted during the acute episode?
Yes

No

Uncertain

10. Was CPR and/or cardioversion performed within 24 hours of death?
Yes

No

Uncertain

24

11. Please give time between onset of acute symptoms to death. (We are
defining death as the point where spontaneous breathing ceased and
the patient never recovered.)
More than 3 days (A)

At least 1 hour, (F)
but less than 4 hours

2 - 3 days (B)
Less than 1 hour (G)
1 day (C)
Death instantaneous,(H)
no symptoms

At least 12 hours, but less than 24 hours (D)
At least 4 hours, but less than 12 hours (E)

Unknown (I)

12. Would you classify the decedent's cause of death as due to CHD?
Yes

No

Uncertain

13. If No, what do you believe to
be the cause of death?
Yes

No Uncertain

a. Pulmonary embolism ..…..
b. Acute pulmonary edema ...
c. Stroke ..............……………
d. Pneumonia .............
e. Other ........….........
Specify: ___________________________________________
C. SIGNATURE
14.Form completed by: _______________________________________
Signature
15.Date:

-Month

-Day

Year

Thank you very much for your help. Please return this questionnaire in the
enclosed self-addressed envelope.
OFFICE USE ONLY: 16. Self (A)__ Interview (B)__ E.R. records (C) __
25