Form 1 ASU

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

ANNUAL STUDY UPDATE and Follow-Up-Form (ASUFLF)

Participant ID: FIELD(9) *FIELD(11)* November 23, 1998

*FIELD(12)*

Participant Name: FIELD(10) Study Year: FIELD(13)

If Your Name (Printed Above) Is Incorrect, Please Record Your Corrected Name Below.

Corrected Name: ____________________________________

1. In the period from FIELD(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)

2a. (If the respondent answered Yes to Q1) If so, what type of cancer(s) were you diagnosed with and on what date were you diagnosed?

Type/Site of Cancer (breast, lung, etc)

Date of Diagnosis _____/______/____ _____/______/____ _____/______/____

2b. What is the name, address and phone number of the doctor who diagnosed you with this (these) cancer(s)? [IF MORE THAN ONE DOCTOR DIAGNOSED THE RESPONDENT WITH CANCER(S) LISTED IN QUESTION 2a, LIST ALL DOCTORS BELOW]. Is Dr. ____________ affiliated with a larger practice? If so, what is the name of Dr. __________’s practice?

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

2c. Have you received treatment for your most recent cancer at a hospital, emergency room, or ambulatory care center affiliated with a hospital? If so, what was the name, address and phone number of the hospital? [IF MORE THAN ONE HOSPITAL, RECORD NAME, ADDRESS AND PHONE NUMBER FOR ALL HOSPITALS].

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

2d. Have you received treatment for your most recent cancer at a radiation treatment center? If so, what was the name, address and phone number of the center? [IF MORE THAN ONE RADIATION TREATMENT CENTER, RECORD NAME, ADDRESS AND PHONE NUMBER FOR ALL CENTERS].

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

2e. Are there any other doctors, hospitals, treatment centers or other healthcare providers who were involved in the treatment of your most recent cancer? [RECORD NAME , ADDRESS AND PHONE NUMBER OF ALL PROVIDERS NAMED BY RESPONDENT].

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

Name:______________________________________ Phone: (____)_________________

Address:__________________________________________________________________

3. FOR MEN ONLY: In the period from FIELD(15) to the present, have you taken the medication
Proscar or Propecia (Finasteride)? Yes [ ] No [ ]

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

5.

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. Rights of study participants are protected by The Privacy Act of 1974. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and report as statistical summaries. |___|___|___| - |___|___| - |___|___|___|___|

6.	What is your current primary home address and telephone number?
STREET ADDRESS APT. NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )
&7.7	What is your work telephone number? (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 7)
TELEPHONE NUMBER: (              ) EXT.

8.8	What is your cell phone number and email address? (IF NOT APPLICABLE, CHECK HERE AND GO TO QUESTION 8)
TELEPHONE NUMBER: (              )		EMAIL ADDRESS:

(OVER)

9.	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 9)
STREET ADDRESS APT. NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )		MONTHS OF YEAR SPENT AT OTHER RESIDENCE (RECORD EXACT DATES IF POSSIBLE) FROM: TO:

10.	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 10)
FULL NAME OF HOUSEHOLD MEMBER RELATIONSHIP TO PARTICIPANT 1.
2.

11.	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 11)
FULL NAME OF PHYSICIAN OR CLINIC
STREET ADDRESS: SUITE OR OFFICE NO.
CITY STATE ZIP
TELEPHONE NUMBER: (              )		FAX NUMBER: (              )

12.	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 AND PHONE TYPE (              ) __________/________ (              ) _________/_________ EMAIL ADDRESS: __________________________________
CITY STATE ZIP
FULL NAME 2.		RELATIONSHIP TO YOU
STREET ADDRESS		TELEPHONE NUMBER AND PHONE TYPE (              ) __________/________ (              ) _________/_________ EMAIL ADDRESS: __________________________________
CITY STATE ZIP
13. Today’s Date: ______/_______/______ Month Day Year 14. Who completed this questionnaire? (Please check one) [ ] Study Participant [ ] Spouse [ ] Someone else (SPECIFY)_______________________ Relationship

15. Comments: ___________________________________________________________________________________

_________________________________________________________________________________________

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

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 Branch Office, 6705 Rockledge Drive, MSC 7974 Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.