SSA_Attachment 1_Data Collection Instruments v2

Supporting Statement A
Attachment 1
List of Data Collection Instruments
•

OS Data collection Instruments
A summary of OS Participant data collection is included in the table below:
Form
Name
Change since
When administered
#
last
submission?
OctOctOct2013
2014
2015

•

33

Medical History Update

No
No

20

Personal Information
Update (1st page only)

151

Activities of Daily Life

No

156

Supplemental
Questionnaire

New

Next of Kin Data Collection Instruments
Form 23: Search to Locate Participant
Form 120: Initial Notification of Death

•

Health Care Provider Data Collection Instruments
Form 120: Initial Notification of Death

Sep2014

Sep2015

Sep2016

X

X

X
X

X

X
X