Download:
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pdfU.S. Radiologic Technologists Study
Fourth Survey
OMB #: 0925-XXXX
Expiration Date: xx/xx/20xx
A collaborative effort between the University of Minnesota School of Public Health, National Cancer Institute,
and American Registry of Radiologic Technologists
Instructions:
• Use blue or black ink
• Print legible numbers:
• Mark check boxes:
1 2 3
(ADDRESS BLOCK FOR WINDOW
ENVELOPE)
○
Right Wrong
×
√
PARTICIPANT NAME
ADDRESS
CITY STATE ZIP
• Do not make any stray marks on this form. If you have
comments, please write them on a separate piece of paper.
GENERAL QUESTIONNAIRE MODULE
Whether you are retired or still working, please complete this questionnaire to update us about your health, radiation
exposure, and other factors. We realize that some questions from the past may be difficult to recall. Just do your best.
Even if not exact, your best estimates are valuable to the study.
1. What is TODAY’S DATE?
2. What is your DATE OF BIRTH?
M M
D
D
M M
D
D
MONTH
MONTH
DAY
DAY
2 0
Y
Y
Y
Y
YEAR
1 9
YEAR
WORK HISTORY
In this questionnaire, “radiologic technologist” includes people working in radiology, nuclear medicine,
radiation therapy or any other diagnostic imaging or therapeutic radiation jobs.
3. Are you currently working
as a radiologic technologist? Yes No →
Year last worked as a radiologic technologist?
Y
Y
Y
Y
Answer the following questions separately for each time period. Just do your best for each question.
4.
5.
Before 1970 1970-1979 1980-1989 1990-1999 2000-2009
Did you work as a radiologic technologist during
each time period? ...........................................................
How many HOURS PER WEEK did you usually work as a
radiologic technologist? ............................................
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
PRIVACY ACT NOTIFICATION STATEMENT
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of
1974. Please be assured that all information you provide will be kept private under the Privacy Act and will not be disclosed to anyone but the researchers conducting this
study, except as otherwise required by law. Any published results from this survey will be reported in statistical summaries only and will never include a participant’s name.
Your participation in this study is completely voluntary and failure to answer any particular question or the information collection as a whole will not affect your future contacts
with the University of Minnesota, the American Registry of Radiologic Technologists, or the National Institutes of Health.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 30 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 (0925-0405). Do not return the completed form to this address.
v2012-03-26
-1-
6.
About how many of each PROCEDURE
type below did you perform or assist
with in a typical WEEK?
Diagnostic x-ray ............................................
Routine fluoroscopy
Chest fluoroscopy ......................................
Upper GI series..........................................
Esophagram (barium swallow) ..................
Oral cholescytogram (gallbladder).............
Small bowel series.....................................
Lower GI series (barium enema) ...............
Retrograde pyelogram/IVP/urethrogram....
For orthopedic or other non-interventional
surgical procedures in the operating room
Fluoroscopically-guided .................................
Diagnostic radioisotope .................................
Brachytherapy................................................
Other therapeutic radioisotope ......................
NEVER
DID
Before 1970
NUMBER OF PROCEDURES PER WEEK
1970-1979
1980-1989
1990-1999
2000-2009
Before 1970 1970-1979 1980-1989 1990-1999 2000-2009
7. When performing diagnostic x-ray procedures,
did you usually have to go into a control booth or
shielded area to turn on the x-ray beam?.............
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
8. Did you ever work as a radiologic technologist in a military hospital or clinic?
No Yes
How many YEARS did you work in this
type of facility?
Before 1970 1970-1979 1980-1989 1990-1999 2000-2009
9. Were you ever removed from working as a radiologic technologist because your radiation exposure exceeded
the allowable limit?
Before 1970 1970-1979 1980-1989 1990-1999 2000-2009
No Yes
How many TIMES did this happen?
10. What is your approximate lifetime total radiation dose received while working as a radiologic technologist
(in mrem)?
Is your lifetime total radiation
Estimated
Unknown Zero
10,000-24,999
dose estimated or taken from
1-999 mrem 25,000-49,999
From dosimetry reports
your dosimetry reports?
1,000-4,999 50,000+
Combination of both
5,000-9,999
-2-
HEALTH HISTORY
Please answer the next questions to let us know if you have been diagnosed with cancer or any of the conditions listed.
11. Did a doctor ever tell you that you had any type of skin cancer?
No (Go to Q12) Yes
Please mark YES for each type of skin
cancer you had and provide your age
when first diagnosed.
TYPE OF SKIN CANCER
(mark all that apply)
YES
AGE FIRST
DIAGNOSED
Basal cell carcinoma . . . . . . . .
For each type of skin cancer you had, how many skin
cancers did you have at each body location?
(If lesion was located on a “side”, choose nearest location)
FRONT OF
HEAD OR
NECK
BACK OF
HEAD OR
NECK
FRONT
OF
TORSO
BACK
OF
TORSO
FRONT
OF
LEGS
BACK
OF
LEGS
ARMS
OR
HANDS
Squamous cell carcinoma . . . .
Melanoma . . . . . . . . . . . . . . . . .
Other or type unknown . . . . . . .
12. Did a doctor ever tell you that you had any other type of cancer?
No (Go to Q13) Yes
Please mark YES for each type of cancer you had and provide your age when first diagnosed.
AGE FIRST
TYPE OF CANCER (mark all that apply) YES DIAGNOSED
Bladder................................................
Lymphoma:
Hodgkin’s disease...........................
Brain or nervous system .....................
Breast:.................................................
Non-Hodgkin’s lymphoma (NHL) ....
If YES:
What type
was it?
Ductal
Other
Invasive Carcinoma Or Type
Left Right
Cancer
In Situ
Unknown
Multiple myeloma ...............................
Ovary .................................................
................. .......... ...........
Pancreas ............................................
................. .......... ...........
Prostate..............................................
Cervix (excluding in situ).....................
Rectum...............................................
Colon...................................................
Salivary gland ....................................
Esophagus ..........................................
Stomach .............................................
Kidney .................................................
Leukemia
Acute myelocytic (AML) ...................
Testis ..................................................
Thyroid ...............................................
Acute lymphocytic (ALL) ..................
Uterus (endometrium) ........................
Chronic myelocytic (CML)................
Chronic lymphocytic (CLL)...............
Liver ....................................................
Lung, trachea, or bronchus .................
Bone....................................................
Which
breast?
AGE FIRST
TYPE OF CANCER (mark all that apply) YES DIAGNOSED
-3-
Other or unknown cancer (specify) ....
_______________________________
13. Did a doctor ever tell you that you had any of the following medical conditions . . . ?
For each medical condition you mark YES, please provide your age when you were first diagnosed.
MEDICAL CONDITION
AGE FIRST
YES DIAGNOSED
(mark all that apply)
Benign tumor of brain or nervous system:
Meningioma ........................................
_____________________________..
Age first removed ...........
YES
Thyroid nodule.......................................
Other conditions:
Goiter (enlarged thyroid)........................
YES
Osteoporosis .........................................
Thyroiditis (Hashimoto’s Disease) .........
Hip fracture ............................................
Hypothyroidism (underactive thyroid) ....
Multiple sclerosis ...................................
Parkinson’s Disease ..............................
Yes
Lupus.....................................................
Graves’ Hyperthyroidism or
Graves’ Disease ....................................
Eye conditions:
AGE
Sleep apnea ..........................................
Benign thyroid tumor (adenoma) ...........
Were you treated (e.g.
surgery,.I-131 drugs) for
hyperthyroidism? .................... No
Eye conditions, cont:
AGE FIRST
YES DIAGNOSED
Did you have any
cataracts removed? ...... No Yes
Other (specify)
If YES, did you take medication
(e.g. synthroid, levothyroxine)
for hypothyroidism? ................ No
(mark all that apply)
Cataract .................................................
Schwannoma or neuroma...................
Thyroid conditions:
MEDICAL CONDITION
Osteoarthritis .........................................
Rheumatoid arthritis ..............................
Scleroderma ..........................................
Yes
Chronic bronchitis..................................
Macular degeneration............................
Emphysema...........................................
Glaucoma ..............................................
Asthma ..................................................
14. Did a doctor ever tell you that you had any of the following CARDIOVASCULAR OR RELATED CONDITIONS?
For each medical condition you mark YES, please provide your age when you were first diagnosed.
MEDICAL CONDITION
(mark all that apply)
AGE FIRST
YES DIAGNOSED DIAGNOSIS AND TREATMENT
NO YES
Angina pectoris.................................
Was the angina confirmed by angiogram? ....................
Heart attack (myocardial infarct) ......
Did you have a coronary bypass, angioplasty, or stent?
Ischemic heart disease.....................
Stroke ...............................................
High blood pressure .........................
Diabetes ...........................................
Was it confirmed by ECG, stress test, or angiogram? ...
Was stroke confirmed by arteriography, CT scan or MRI? .
Do you currently take blood pressure medication?........
Do you currently take insulin?........................................
-4-
PERSONAL DIAGNOSTIC RADIATION EXAMS
15. Please provide your age(s) at first and last exam. Please indicate APPROXIMATELY how many times you
had the following selected diagnostic radiation exams during each time period. Count the number of exams
that you had, NOT the number of individual films taken. (If you never had a specific exam, mark the box
“never had” and leave all other columns blank. )
X-RAY exams performed ON YOU
Dental
Bite-wing ..............................................
Panoramic x-ray...................................
Skull..........................................................
Sinus ........................................................
Neck and soft tissue .................................
Spine
Full .......................................................
Cervical ................................................
Thoracic ...............................................
Lumbar.................................................
Lumbosacral ........................................
Ribs ..........................................................
Abdomen ..................................................
Pelvis........................................................
Sacrum .....................................................
Mammogram ............................................
FLUOROSCOPY exams performed
ON YOU with or without X-Rays
NEVER
HAD
NUMBER OF EXAMS BY TIME PERIOD
1970-1979 1980-1989 1990-1999 2000-2009
NEVER AGE 1ST
HAD
EXAM
Cardiac angiogram or catheterization.......
Pulmonary arteriogram .............................
<1970
Cardiac angioplasty or stent placement ...
AGE LAST
EXAM
Cerebral arteriogram ................................
Carotid arteriogram...................................
AGE 1ST
EXAM
-5-
AGE LAST
EXAM
NUMBER OF EXAMS BY TIME PERIOD
<1970
1970-1979 1980-1989 1990-1999 2000-2009
FLUOROSCOPY exams performed ON YOU
with or without X-Rays, continued
NEVER AGE 1ST
HAD
EXAM
Upper GI series.........................................
Liver, gallbladder, or bile ducts .................
Esophagram (barium swallow) .................
Small bowel series ....................................
Lower GI series (barium enema) ..............
TOMOGRAPHY or CT scans performed ON
YOU (Count exams taken with and without
contrast separately.)
NEVER
HAD
Abdomen without pelvis............................
CT angiography ........................................
RADIONUCLIDE tests performed ON YOU
NEVER
HAD
Liver scan .................................................
Renogram.................................................
Bone scan ................................................
<1970
Thyroid uptake or function........................
Lung scan.................................................
AGE LAST
TEST
Cardiac scan ............................................
AGE 1ST
SCAN
Brain scan ................................................
Thyroid scan.............................................
NUMBER OF SCANS BY TIME PERIOD
<1970 1970-1979 1980-1989 1990-1999 2000-2009
Chest ........................................................
Abdomen with pelvis.................................
AGE LAST
SCAN
Spine ........................................................
NUMBER OF EXAMS BY TIME PERIOD
<1970 1970-1979 1980-1989 1990-1999 2000-2009
Head .........................................................
Neck .........................................................
AGE LAST
EXAM
AGE 1ST
TEST
-6-
NUMBER OF TESTS BY TIME PERIOD
1970-1979 1980-1989 1990-1999 2000-2009
PERSONAL THERAPEUTIC RADIATION PROCEDURES
16. Please indicate APPROXIMATELY how many times you had radionuclide therapy procedures performed on
you for the selected medical conditions below. Also provide your age(s) at first and last treatment.
RADIONUCLIDE THERAPY procedures
performed ON YOU for the following
medical conditions:
NEVER AGE 1ST
HAD TREATED
Hyperthyroidism .......................................
Leukemia..................................................
Thyroid cancer or ablation........................
Non-Hodgkin’s lymphoma ........................
Polycythemia vera ....................................
Other (please specify)
_________________________________
AGE LAST
TREATED
NUMBER OF TREATMENTS BY TIME PERIOD
<1970 1970-1979 1980-1989 1990-1999 2000-2009
17. Please indicate how many times you had radiation therapy (radiotherapy, cobalt therapy) to any of the
following body areas during each time period, first for CANCERS and then for P conditions, and your
age(s) at first and last treatment.
If you had a treatment series for a single cancer occurrence, count as one treatment.
RADIATION THERAPY procedures
performed ON YOU to the following body
areas for CANCER conditions:
NEVER
HAD
Head .........................................................
Chest (including breast)............................
Neck .........................................................
Spine ........................................................
Abdomen ..................................................
AGE 1ST
TREATED
AGE LAST
TREATED
NUMBER OF TREATMENTS BY TIME PERIOD
CANCER (series)
<1970 1970-1979 1980-1989 1990-1999 2000-2009
For non-cancer conditions, count the number of individual treatment sessions that you had.
RADIATION THERAPY procedures
performed ON YOU to the following body
areas for NON-CANCER conditions:
NEVER
HAD
Head .........................................................
Chest (including breast) ............................
Neck..........................................................
Spine.........................................................
Abdomen ..................................................
AGE 1ST
TREATED
-7-
AGE LAST
TREATED
NUMBER OF TREATMENTS BY TIME PERIOD
NON-CANCER (sessions)
<1970 1970-1979 1980-1989 1990-1999 2000-2009
WOMEN ONLY - Men go to Page 9, Question 24
18. Have you ever given birth?
No Yes
20. Have your menstrual periods stopped
permanently (i.e., no period for at least six months)?
For each birth please complete the following
questions (Include still births. Exclude step- or
adopted children).
Birth
Order
Year of birth
First
Did you breast
feed this baby?
No Yes
Yes
How
many
months?
No, menstrual periods are irregular or using
hormones
Never menstruated
21. Did you have surgery to remove your uterus or
ovaries? (Mark all that apply)
No Yes
Second
Yes, uterus removed
No Yes
Fourth
Yes, one or both
ovaries removed
No Yes
Fifth
Ages when removed?
No
No Yes
Third
AGE STOPPED
No, still having periods
Please list any additional births on a separate piece of
paper and return with this form.
No Yes
Total number of
years taken?
AGE
Currently taking?
AGE
Number of times?
AGE
STARTED
Age started taking?
No Yes
Age when last diagnosed?
SECOND
22. Did you ever take prescription hormone
replacement therapy for symptoms of menopause?
19. Did a doctor ever tell you that you had postpartum
mastitis?
Age when first diagnosed?
FIRST
NO. TIMES
YEARS
No Yes
23. Did you ever have a breast biopsy (or aspiration)?
No Yes
Age at time of first biopsy/aspiration?
Number of biopsies/aspirations?
AGE
NUMBER
Reason for biopsy or aspiration? (Mark all that apply)
Did any biopsy or aspiration lead
to a diagnosis of. . .
Breast cancer or ductal
carcinoma in situ ......................
Yes
Atypia or atypical hyperplasia ..
Yes
Fibroadenoma..........................
Yes
Hyperplasia without atypia .......
Abnormal
Abnormal
Self-exam
physician
AGE FIRST
(e.g. lump, pain,
exam
DIAGNOSED?
discharge)
Yes
-8-
Abnormal
Abnormal
screening
diagnostic
mammogram mammogram
WOMEN and MEN complete remainder of Questionnaire.
The following questions will help us understand whether these factors may be related to health for people
working in the field of medical radiation. Please answer to the best of your knowledge.
24. How tall are you without shoes?
FEET
INCHES
25. How much do you weigh without shoes and clothes?
26. Do you currently smoke cigarettes?
No Yes
POUNDS
How many cigarettes do you usually
smoke per day? ................................................
How soon after you wake up do you usually
smoke your first cigarette of the day? ...........
How many days per week do you usually
smoke cigarettes? ............................................
NUMBER PER DAY
Within 5 minutes 6-30 minutes
31-60 minutes
More than 60 minutes
DAYS PER WEEK
Are you an ex-smoker?
No Yes
What year did you last smoke cigarettes?
27. How much did you weigh when you were born?
28. Were you breastfed as a baby?
29. Were you born premature?
YEAR LAST SMOKED
POUNDS
OUNCES
No Yes Don’t know
No Yes Don’t know
30. Have any of your blood-related parents, siblings,
or children had any of the following primary cancers?
(Mark all that apply)
Brain cancer........................................................
Breast cancer......................................................
Thyroid cancer ....................................................
Leukemia, lymphoma, or multiple myeloma .......
Lung cancer ........................................................
Yes
Yes
Yes
Yes
Yes
31. How many TIMES did you visit a medical facility or
clinic for a ROUTINE PHYSICAL (exam)?
Pap smear (women only) ..........................................................
Breast exam (women only) .......................................................
Prostate exam (men only) .........................................................
Sigmoidoscopy or colonoscopy.................................................
General physical exam..............................................................
-9-
YOUNGEST age any of these relatives were first diagnosed
Under
age 40
Age
30-39
40-49
50-59
60-69
Age 70
or older
TOTAL NUMBER OF EXAMS
Age
40-49
Age
50-59
Age
60-69
Age
Unknown
Age 70
or older
IN THE PAST YEAR
The following questions will allow us to evaluate physical activity and health in the USRT Study.
32. During the PAST YEAR, how many HOURS per week
did you. . .
Walk for exercise..................................................................
NUMBER OF HOURS PER WEEK
NONE
½ hr
1 hr
1-½
2-3
4-6
7-10
11 hours
or more
Walk for daily activities other than for exercise (e.g.at
work, shopping) ...................................................................
Strenuous aerobic exercise such as jogging, running,
bicycling (including stationary), swimming, playing tennis,
treadmill, stairmaster, dance ...............................................
Weight training or resistance exercises (e.g. weight
machines, free weights) ......................................................
NONE
1-2
Sitting watching TV, video or DVD ........................................
Other sitting (reading, knitting, using a computer) ................
Sitting or driving in a car, bus or train....................................
Yoga or Pilates .....................................................................
33. During the PAST YEAR, how many HOURS per day
did you spend . . . (mark only one response per activity)
NUMBER OF HOURS PER DAY
3-4
5-6
7-8
9-10
11-12
13 hours
or more
The following questions will allow us to evaluate sleep patterns and health in the USRT Study.
34. During the PAST YEAR, how many HOURS
per day did you sleep in a typical 24-hour
period on:
TIME
1-4
WEEKDAYS
WEEKENDS
35. During the PAST YEAR, how many TIMES in a
typical week were your daily activities adversely
affected because you got too little sleep? ..............................
36. During the PAST YEAR, how much light was visible
in your bedroom while you slept? .............................................
37. During the PAST YEAR, did you go to bed
after midnight at least once a week for at least
three months?
No Yes
None
1
Bright light
(e.g. to read)
6
12:00 to
1:00 am
-10-
1:00 to
2:00 am
2:00 to
3:00 am
7
8
9
TIMES PER WEEK
2-3
4-5
AMOUNT OF LIGHT
Some light
(night light)
What was your
USUAL BEDTIME after midnight?
38. What type of person do you generally consider yourself?
Morning person
Evening person
Neither
Both
5
HOURS OF SLEEP PER DAY
After
3:00 am
6-7
10 hours
or more
8 or
more
Completely
dark
About how many TIMES
PER MONTH did you go
to bed after midnight?
1-4
5-8
9-15
16+
39. During the PAST YEAR,
did you take any of the
following supplements?
NO YES
How many DAYS
PER WEEK did
you take?
Multivitamins .........................
Calcium (including Tums)...
What was the total dosage (mg) of
calcium per day?
Vitamin D (alone or in a
calcium supplement)..........
What was the total dosage (IU) of
Vitamin D per day?
Other supplements taken
separately from a multi-vitamin:
Less than 500 mg 900-1299 1600 or more
1300-1599
500-899
Less than 400 IU 800-1399 2000-3999
1400-1999 4000 or more
400-799
All year
Winter only
IN YOUR LIFETIME
40. Have you EVER used a SUNLAMP for tanning or to treat a skin condition?
No Yes
How old were you the FIRST
time you used a sunlamp?
Under 13 years old
13-19
20-39
40-64
Age 65 or older
How old were you the LAST
time you used a sunlamp?
Under 13 years old
13-19
20-39
40-64
Age 65 or older
1-2 times
3-4
5-9
10-19
20 times or more
How old were you the LAST
time you used a tanning booth
or tanning bed?
How many times did you
use a tanning booth or
tanning bed in your life?
41. Have you EVER used a TANNING BOOTH or TANNING BED?
No Yes
How old were you the FIRST
time you used a tanning booth
or tanning bed?
Under 13 years old
13-19
20-39
40-64
Age 65 or older
How many times did you
use a sunlamp in your life?
Under 13 years old
13-19
20-39
40-64
Age 65 or older
1-2 times
3-4
5-9
10-19
20 times or more
42. How many MONTHS PER YEAR did you usually have a TAN FROM SUN EXPOSURE at each age listed below?
Under 13
years old
Never had a tan
1-3 months
4-6
7-9
10-12 months
13-19
Never had a tan
1-3 months
4-6
7-9
10-12 months
20-39
Never had a tan
1-3 months
4-6
7-9
10-12 months
-11-
40-64
Never had a tan
1-3 months
4-6
7-9
10-12 months
Age 65
or older
Never had a tan
1-3 months
4-6
7-9
10-12 months
43. HOW OFTEN did you protect yourself from the sun by wearing a long-sleeve shirt or long pants, when you were
in the sun on a typical day in the summer at each age listed below?
Under 13
years old
13-19
20-39
Never
Rarely
Sometimes
Usually
Always
Never
Rarely
Sometimes
Usually
Always
40-64
Never
Rarely
Sometimes
Usually
Always
Never
Rarely
Sometimes
Usually
Always
Age 65
or older
Never
Rarely
Sometimes
Usually
Always
When answering the next two questions about “night shift” work, please include ANY jobs held during your lifetime.
By “Night shift” we mean working 3 or more hours during 12:00-5:00 AM for 6 months or more.
44. Did you ever work
PERMANENT night shifts
at this age?
AGE
NO
Under age 30 No
YES
Yes
30-39 No Yes
40-49 No Yes
Age 50 or older No Yes
During how many
YEARS did you work
PERMANENT night
shifts at this age?
8 or
2-3 4-5 6-7 more
1
On average, how many
PERMANENT NIGHT
SHIFTS did you work PER
MONTH at this age?
20 or
3 4-5 6-9 10-14 15-19 more
45. Did you ever work
ROTATING night shifts
at this age?
AGE
NO
No
30-39 No
40-49 No
Age 50 or older No
Under age 30
YES
Yes
Yes
Yes
Yes
WORK HISTORY WITH FLUOROSCOPICALLY-GUIDED OR
RADIOISOTOPE PROCEDURES
46. Did you perform or assist with FLUOROSCOPICALLY-GUIDED medical
radiation procedures at least once a month for a year or more?
No Yes
We are interested here in fluoroscopically-guided procedures that use catheters or other types of equipment for diagnosis or intervention, including cardiac procedures (such as diagnostic catheterization, electrophysiology studies,
pacemaker implant), urology procedures (such as nephrostomy), orthopedic procedures (such as vertebroplasty),
gastrointestinal procedures (such as TIPS, ERCP), embolization procedures (such as fibroids, liver tumor), and
other fluoroscopically-guided procedures (such as port placement, peripheral vascular intervention). Do NOT
include routine fluoroscopy exams (such as upper GI series, esophagram, barium enema).
47. Did you perform or assist with DIAGNOSTIC OR THERAPEUTIC
RADIOISOTOPE procedures at least once a month for a year or more?
No Yes
If you answered YES to Question 46 or 47, you may receive a follow-up questionnaire in the future.
In case we need to contact you, please provide a telephone number and best time to reach you.
Phone
number
AREA CODE
-
Best time to call: WEEK DAY
-
PHONE NUMBER
WEEK NIGHT WEEKEND
Thank you!
-12-
OFFICE USE ONLY
A B C D E
| File Type | application/pdf |
| File Title | USRT_4Survey |
| File Modified | 2012-03-28 |
| File Created | 2012-03-28 |