3 Clinical Exam Questioniare

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

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EXP. XX/XXXX

Clinical Exam Questionnaire
(Estimated Burden: 15 minutes)

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including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
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National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Table of Contents

Clinical Exam Check-In .......................................................................................3
Informed Consent................................................................................................4
Background Questions .......................................................................................5
Height Measurement(s).....................................................................................14
Weight Measurement(s) ....................................................................................15
Waist Circumference Measurement.................................................................16
Hip Circumference Measurement ....................................................................17
Physiological Measures- Heart Rate & Blood Pressure.................................18
Biological Specimen Collection- Blood...........................................................19
Biological Specimen Collection – Quality Control Blood Samples ..............22
Biological Specimen Collection – Finger Stick ..............................................23
Biological Specimen Collection- Saliva Practice and Instruction .................24
Biological Specimen Collection – Urine ..........................................................25
Biological Specimen Collection- Hair ..............................................................28
Biological Specimen Collection- Toenails ......................................................29
Biological Specimen Collection- Exhaled Breath Condensate (EBC) ..........31
Neurobehavioral Test........................................................................................32
Peripheral Nerve Tests .....................................................................................35
Hand/Grip Strength Test ...................................................................................49
Exhaled Nitric Oxide (eNO) ...............................................................................51
Exhaled Breath Condensate Test (EBC) .........................................................53
Pulmonary Function Testing (PFT) ..................................................................54
Medical Referrals...............................................................................................56
Check-Out, Review and Remuneration ...........................................................57

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Section A: Clinical Exam Check-In
[PROGRAMMER NOTE: AUTO-POPULATE CONTACT INFORMATION AND
DISPLAY=FIRST, MIDDLE AND LAST NAME, SUFFIXES OR SURNAMES, E-MAIL
ADDRESSES, PHONE NUMBERS, STREET ADDRESS, MAILING ADDRESS AND
SECONDARY CONTACT INFORMATION. AUTO-POPULATE AND DISPLAY
DEMOGRAPHIC INFORMATION=AGE, DATE OF BIRTH, RACE AND GENDER/SEX
ON SCREEN]
[EXAMNINER NOTE: CONFIRM PARTICIPANT’S CONTACT AND DEMOGRAPHIC
INFORMATION AND MAKE CHANGES, UPDATES AND CORRECTIONS AS
NECESSARY; REFER TO MANUAL FOR ADDITIONAL CHECK-IN INSTRUCTIONS]
A1. ENTER PARTICIPANT’S VISIT START DATE
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
A2. ENTER PARTICIPANT’S VISIT START TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
PROGRAMMER NOTE: AUTO-POPULATE PARTICIPANT ID/GULF ID. ID
CONVENTION= SITE#-PID/GULF ID-CHECK SUM DIGIT.
A3. ENTER EXAMINER ID FOR CLINICAL VISIT
[FREE TEXT FIELD_NUMERIC]

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Section B: Informed Consent
[PROGRAMMER NOTE: AUTO TIME STAMP]
B1. ENTER CONSENT DATE

_____/_____/______ [MM/DD/YYYY]
[PROGRAMMER NOTE: ADD LOGIC CHECK FOR DATA ENTRY OF CONSENT
VERSION #]
B2. RECORD CONSENT VERSION #
I___I___I.I___I
B2a. DID THE PARTICIPANT CONSENT TO THE CLINICAL EXAM?
YES ........................ 1 [GO TO SECTION C]
NO .......................... 2
B3b. REASON FOR CONSENT REFUSAL
[FREE TEXT FIELD]
[PROGRAMMER NOTE: IF NO, DISPLAY MESSAGE= END CLINICAL EXAM. BLOCK
FURTHER DATA ENTRY]

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Section C: Background Questions
C1. What is the highest grade or level of school you have completed or the highest
degree you have received?
NEVER ATTENDED/KINDERGARTEN ONLY ............................................ 1
1ST GRADE .................................................................................................. 2
2ND GRADE .................................................................................................. 3
3RD GRADE .................................................................................................. 4
4TH GRADE .................................................................................................. 5
5TH GRADE .................................................................................................. 6
6TH GRADE .................................................................................................. 7
7TH GRADE .................................................................................................. 8
8TH GRADE .................................................................................................. 9
9TH GRADE .................................................................................................. 10
10TH GRADE ................................................................................................ 11
11TH GRADE ................................................................................................ 12
12TH GRADE, NO DIPLOMA ........................................................................ 13
HIGH SCHOOL GRADUATE ....................................................................... 14
GED OR EQUIVALENT ............................................................................... 15
SOME COLLEGE, NO DEGREE ................................................................. 16
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL
OR VOCATIONAL PROGRAM .................................................................... 17
ASSOCIATE DEGREE: ACADEMIC PROGRAM ........................................ 18
BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA)............................. 19
MASTER’S DEGREE (EXAMPLE: MA, MS, MEng, MEd, MBA) .................. 20
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD)................................................................. 21
DOCTORAL DEGREE (EXAMPLE: PhD, EdD) ........................................... 22
DON’T KNOW .............................................................................................. 88
REFUSED .................................................................................................... 99
C2. What language do you speak at home?
English ...............................1
Spanish .............................2
Vietnamese........................3
Creole ................................4
Other [FREE TEXT FIELD] 5
DON’T KNOW ...................8
REFUSED .........................9
C3. Are you currently pregnant? [PROGRAMMER NOTE: ONLY ASK IF
GENDER=FEMALE]
YES ................................... 1
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ........................ 9
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C4. In the past 12 months, has a doctor told you that you had an ear infection?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION C5]
DON’T KNOW ................... 8 [GO TO QUESTION C5]
REFUSED ........................ 9 [GO TO QUESTION C5]
C4a. What was the month and year of your diagnosis?
__ __/__ __ __ __ [MM/YYYY]
DON’T KNOW ........ 8
REFUSED ............. 9
C4b. Was the ear infection treated with antibiotics?
YES ........................ 1
NO .......................... 2
DON’T KNOW ........ 8
REFUSED ............. 9
C5. Has a doctor ever told you that you have any of the following conditions or diseases
or have you had any of the following procedures…?
Condition or
Procedure

C5a. Inner Ear
Surgery

C5b. Brain Tumor

C5c. Polio

C5d. Amyotrophic
lateral sclerosis

C5e. Multiple
sclerosis

Have Condition/had
Procedure?

If yes, month/year of
procedure or
diagnosis of
condition
[MM/YYYY]

Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused

Comments/Notes

[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __

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C5f. Parkinson’s
disease

C5g. Stoke

C5h. Low thyroid
gland function

C5i. Diabetes

C5j. Retinal/macular
degeneration

Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused

[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __
[free text field]
__ __/__ __ __ __

C6. Are you currently under a doctor's care for any other short-term or long-term illness
(es) or conditions not listed above?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION C7]
DON’T KNOW ................... 8 [GO TO QUESTION C7]
REFUSED ........................ 9 [GO TO QUESTION C7]
C6a. What illnesses or conditions do you have? RECORD FIRST ILLNESS OR
CONDITION [PROGRAMMER NOTE: LOOP THESE QUESTIONS SO THAT IF
YES IS SELECTED, FREE TEXT FIELD IS DISPLAYED FOR DATA ENTRY OF
ILLNESS OR CONDITION]
[FREE TEXT FIELD] ___________________________________
C7. Have you ever had a head injury?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION C10]
DON’T KNOW ........ 8 [GO TO QUESTION C10]
REFUSED ............. 9 [GO TO QUESTION C10]
C7a. In what month and year were you diagnosed?
__ __/__ __ __ __ [MM/YYYY]
DON’T KNOW ........ 8
REFUSED .............. 9
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C8. Have you ever had a head injury where you lost consciousness?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION C9]
DON’T KNOW ................... 8 [GO TO QUESTION C9]
REFUSED ........................ 9 [GO TO QUESTION C9]
C8a. How many times in your life have you had a head injury that resulted in loss
of consciousness?
__ __ __ TIMES
DON’T KNOW ...................8
REFUSED .........................9
C8b. How many of these were diagnosed by a health care provider?
ALL OF THEM ...................1
SOME OF THEM ...............2
JUST ONE .........................3
NONE OF THEM ...............4
DON’T KNOW ...................8
REFUSED .........................9
[PROGRAMMER: LOOP THROUGH THE FOLLOWING QUESTIONS FOR EACH
HEAD INJURY WITH LOSS OF CONSCIOUSNESS.]
Head
Injury

1

When did your
head injury with
loss of
consciousness
occur?
__ __/__ __ __ __

Approximately
how long were
you unconscious?

<30 min

>30 min

Don’t Know

Refused

Did you seek
medical treatment
for your head injury?

Hospitalized
overnight?

Yes

No

Refused

Yes

No

Refused

Were you hospitalized
over-night as a result of
your head injury?
[If yes, record the total #
of days spent in the
hospital]

How did
head
injury
occur?

If other for how
head injury
occurred, specify
here

I_I_I_I

Job event

[FREE TEXT

Off the job

FIELD]

MV Accid.
Work on
Farm
Work off
Farm
Other
Don’t
Know

2

__ __/__ __ __ __

3

__ __/__ __ __ __

4

__ __/__ __ __ __

<30 min
>30 min
Don’t Know
Refused
<30 min
>30 min
Don’t Know
Refused
<30 min
>30 min
Don’t Know

Yes

No

Refused

Yes

No

Refused

I_I_I_I

“

”

[FREE TEXT
FIELD]

Yes

No

Refused

Yes

No

Refused

I_I_I_I

“

”

[FREE TEXT
FIELD]

Yes

No

Refused

Yes

No

Refused

I_I_I_I

“

”

[free text field]

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Refused

5

__ __/__ __ __ __

<30 min
>30 min
Don’t Know
Refused

Yes

No

Refused

Yes

No

Refused

I_I_I_I

“

”

[free text field]

C9. Have you ever had a concussion?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION C10]
DON’T KNOW ................... 8 [GO TO QUESTION C10]
REFUSED ........................ 9 [GO TO QUESTION C10]
C9a. How many times in your life have you had a concussion?
__ __ __ TIMES
DON’T KNOW ...................8
REFUSED .........................9
C9b. How many of these were diagnosed by a health care provider?
ALL OF THEM ...................1
SOME OF THEM ...............2
JUST ONE .........................3
NONE OF THEM ...............4
DON’T KNOW ...................8
REFUSED .........................9
C10. Do you take any prescription or over the counter medications regularly? This
includes any minerals, vitamins and herbal supplements and those medications that are
taken in forms other than a pill or capsule, such as a daily shot, inhalers, liquids, gels,
creams, sprays, patches or suppositories etc.
Yes .................................... 1
No...................................... 2
DON’T KNOW ................... 8
REFUSE ........................... 9
[EXAMINER NOTE: IF YES, ASK THE STUDY PARTICIPANT IF THEY HAVE THEIR
MEDICATION WITH THEM. IF SO, RECORD THE INFORMATION DIRECTLY FROM
THE DRUG LABEL BELOW. IF NOT, THEN ASK THEM TO TELL YOU ABOUT EACH
MEDICATION THEY TAKE REGULARLY (BOTH PRESCRIPTION AND OVER-THE
COUNTER) AND RECORD THE INFORMATION BELOW.]

Drug

1

What is
the
name of
the
drug?

What is
the reason
for taking
this drug?

[Free
text
field]

[Free text
field]

What is the
dosage(
enter
amount per
day)?
I_I_I_I_I

Enter
dosage
units

mg
IU
Mcg
mL
g

9

If “other”
dosage
unit,
specify
here

[Free text
field]

How many
times a day
do you take
this drug?

I_I_I_I_I

When did you
start taking
this drug?
[MM/YYYY]
__ __/__ __ __

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tbsp
tsp
other

2

3

4

5

6

7

8

9

10

[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]
[Free
text
field]

[Free text
field]
[Free text
field]

I_I_I_I_I

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

“ “

“ “

“ “

“ “

“ “
“ “

“ “

“ “
“ “

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

[Free text
field]

I_I_I_I_I

C11. Do you usually drink 1 or more beverages containing caffeine a day?
YES ................................... 1
NO ..................................... 2
DON’T KNOW ................... 8
REFUSE ........................... 9
C12. How long has it been since you last drank a caffeinated beverage?
I_I_I_I UNITS
MINUTES .......................... 1
HOURS ............................. 2
DAYS ................................ 3
DON’T KNOW ................... 8
REFUSE ........................... 9

10

__ __/__ __ __

__ __/__ __ __

__ __/__ __ __
__ __/__ __ __

__ __/__ __ __

__ __/__ __ __

__ __/__ __ __
__ __/__ __ __

__ __/__ __ __

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C13. Have you ever smoked cigarettes or used other tobacco products on a daily
basis?
No, never........................................................................................... 1
Yes, in the past, but not currently ...................................................... 2
Yes, I currently use cigarettes or tobacco products on a daily basis . 3
DON’T KNOW ................................................................................... 8
REFUSE............................................................................................ 9
C13a. How long has it been since you last smoked or used tobacco products?
I__I__I__I UNITS
MINUTES ..........................1
HOURS .............................2
DAYS .................................3
DON’T KNOW ...................8
REFUSED .........................9
C14. How long has it been since you last drank alcohol?
I__I__I__I UNITS
MINUTES .......................... 1
HOURS ............................. 2
DAYS ................................ 3
YEARS .............................. 4 [GO TO QUESTION C19]
I DON’T DRINK ................. 5 [GO TO QUESTION C19]
DON’T KNOW ................... 8
REFUSE ........................... 9
C15. During the past 12 months, about how many drinks containing alcohol did you
have on a typical weekend? (A typical weekend is Friday evening through Sunday
evening. One can of beer, one glass of wine, or one shot of liquor counts as one drink).
I_I_I_I # drinks
DON’T KNOW ................... 8
REFUSE ........................... 9
C16. During the past 12 months, about how many drinks containing alcohol did you
have during a typical week? (A typical week is Monday through Friday afternoon. One
can of beer, one glass of wine, or one shot of liquor counts as one drink).
I_I_I_I # drinks
DON’T KNOW ................... 8
REFUSE ........................... 9
C17. During the past 12 months, about how many times did you have 5 or more drinks
containing alcohol on one occasion?
I_I_I_I # times
DON’T KNOW ................... 8
REFUSE ........................... 9

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C18. Now, please think about your use of alcohol throughout your life. Have you ever
sought help to cut back or stop drinking?
Yes .................................... 1
No...................................... 2
DON’T KNOW ................... 8
REFUSE ........................... 9
C19. Have you ever worked with or been exposed to any of the following chemicals for
8 hours a week or more in a past job, your present job, at home (i.e. hobbies), or any
other locations where you spend time?
Chemical

C19a. Gasoline

C19b. Paint
Lacquer/Thinner
C19c.
Turpentine

C19d. Benzene

C19e. Toluene

C19f. Petroleum
Distillates

C19g. Welding
Fumes
C19h. Soldering
Products

Exposed? Y/N

Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused
Yes
No
Don’t Know
Refused

Start/Stop Date (yr)
[YYYY/YYYY]

Comments/Notes

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

__ __ __ __/__ __ __ __

[Free text field]

C20. How much sleep did you get last night? Would you say…
About the usual amount .... 1
Less than usual ................. 2
More than usual ................ 3
DON’T KNOW ................... 8
REFUSED ......................... 9
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Section D: Height Measurement(s)

Height
Measurement

Height
(cm)

Measurement 1
Measurement 2

Measurement 3

Obtained?

Refused?

I_I_I_I.I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

I_I_I_I.I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Yes

No

Yes

No

I_I_I_I.I_I

Reason not obtained

[FREE TEXT FIELD]

[PROGRAMMER NOTE: DISPLAY AVERAGE HEIGHT MEASUREMENTS AND
CONVERT TO INCHES FOR PARTICIPANT REPORTING.]
I_I_I.I_I INCHES CONVERSION

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Section E: Weight Measurement(s)
Weight
Measurement

Weight
(kg)

Measurement 1

Obtained?

Refused?

Reason not obtained

I_I_I_I.I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Measurement 2

I_I_I_I.I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Measurement 3

I_I_I_I.I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

[PROGRAMMER NOTE: INSERT AVERAGE WEIGHT CALCULATION IN KG, ALONG
WITH BMI FROM PREVIOUS MEASUREMENTS AND CALCULATE CONVERSION
TO LBS FOR PARTICIPANT REPORTING]
I_I_I_I.I_I lbs
I_I_I.I_I BMI
[PROGRAMMER NOTE: INCLUDE POP UP MESSAGE THAT TELLS INTERVIEWER
WHICH BMI CATEGORY TO SELECT. SHOW MESSAGE= DON’T FORGET TO GIVE
PARTICIPANT THEIR BMI RESULTS HANDOUT.]

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Section F: Waist Circumference Measurement

Waist Circum.
Measurement

Waist
Circumference
(cm)

Measurement 1

Measurement 2

Measurement 3

Obtained?

Refused?

I_I_I_I. I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

I_I_I_I. I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Yes

No

Yes

No

I_I_I_I. I_I

16

Reason not obtained

[FREE TEXT FIELD]

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Section G: Hip Circumference Measurement

Hip Circum.
Measurement

Hip
Circumference
(cm)

Measurement 1

I_I_I_I. I_I

Measurement 2

I_I_I_I. I_I

Measurement 3

I_I_I_I. I_I

Reason not
obtained

Obtained?

Refused?

Yes

No

Yes

No

[FREE TEXT FIELD]

Yes

No

[FREE TEXT FIELD]

Yes

No

[FREE TEXT FIELD]

Yes

No

Yes

No

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Section H: Physiological Measures- Heart Rate & Blood Pressure
I will now take your blood pressure and heart rate. This should only take a few minutes.
RECORD PARTICIPANT’S BLOOD PRESSURE AND HEART RATE. [PROGRAMMER
NOTE: IF THE AVERAGE OF THE LAST TWO SYSTOLIC BP ≥ 180 OR DIASTOLIC
BP ≥ 110 OR HEART RATE ≤ 40 OR ≥ 150, SKIP PFT AND LONG-DISTANCE
CORRIDOR WALK]

Blood Pressure
Measurement

Blood
PressureSystolic/
Diastolic

Heart
Rate

Obtained?

Refused?

Measurement 1

I_I_I_I /
I_I_I_I

I_I_I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Measurement 2

I_I_I_I /
I_I_I_I

I_I_I_I

Yes

No

Yes

No

[FREE TEXT FIELD]

Measurement 3

I_I_I_I /
I_I_I_I

I_I_I_I

Yes

No

Yes

No

AVERAGE BLOOD PRESSURE I_I_I_I / I_I_I_I
AVERAGE FOR HEART RATEI_I_I_I

18

Reason not obtained

[FREE TEXT FIELD]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section I: Biological Specimen Collection- Blood
I1. WAS BLOOD COLLECTED?
YES ............. 1
NO ............... 2 [GO TO I1c]
I1a. DATE OF BLOOD COLLECTION
_____/_____/______ [MM/DD/YYYY]
I1b. TIME OF BLOOD COLLECTION
__/__/: __/__/ [HH/MM] [GO TO QUESTION I2]
AM …….1
PM……..2
I1c. IF NOT COLLECTED, PROVIDE A REASON
UNABLE TO COLLECT ..................................... 1 [GO TO SECTION J]
MEDICAL REASON .......................................... 2 [GO TO SECTION J]
EQUIPMENT MALFUNCTION .......................... 3 [GO TO SECTION J]
OTHER [FREE TEXT FIELD] ............................ 4 [GO TO SECTION J]
DON’T KNOW ................................................... 8 [GO TO SECTION J]
REFUSED ......................................................... 9 [GO TO SECTION J]
I2. RECORD
Blood Draw
Attempt

Attempt 1

Attempt 2

Attempt 3

Appendage
used?

Right Arm
Right Hand
Left Arm
Left Hand
Not Applicable
Right Arm
Right Hand
Left Arm
Left Hand
Not Applicable
Right Arm
Right Hand
Left Arm
Left Hand
Not Applicable

Vein used?

Cephalic
Median Cubital
Basilic
Other
Not Applicable
Cephalic
Median Cubital
Basilic
Other
Not Applicable
Cephalic
Median Cubital
Basilic
Other
Not Applicable

I3. DID YOU COLLECT THE FOLLOWING TUBES?

19

If “other”
vein, which
vein used?

Blood
Collected?

[FREE TEXT
FIELD]

Yes
No
Refused

[FREE TEXT
FIELD]

Yes
No
Refused

Yes
No
Refused

[FREE TEXT
FIELD]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Tube
Color

Red

Collected?

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Royal
Blue

Yes
No
Refused

Paxgene

Yes
No
Refused

Red

Lavender

Lavender

Yellow

If “other” or refused,
specify

If no, why?

Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other
Unable to collect
Medical Reason
Equipment
Malfunction
Spilled
Refused
Other

20

[Free text Field]

[Free text Field]

[Free text Field]

[Free text Field]

[Free text Field]

[Free text Field]

[Free text Field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

21

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section J: Biological Specimen Collection – Quality Control Blood Samples
[PROGRAMMER NOTE: ONLY DISPLAY IF PARTICIPANT IS FLAGGED FOR
QUALITY CONTROL/QUALITY ASSURANCE SAMPLES]
J1. WAS PARTICIPANT SELECTED FOR QUALITY CONTROL BLOOD DRAW?
YES ............. 1
NO ............... 2 [GO TO SECTION K]
J2. DID THE PARTICIPANT AGREE TO THE COLLECTION OF ADDITIONAL
QUALITY CONTROL BLOOD TUBES?
YES ............. 1
NO ............... 2 [GO TO SECTION K]
QC SUB QUESTIONS
J3. DID YOU COLLECT THE FOLLOWING QUALITY CONTROL TUBES?
Tube Color

Red

Collected?

Yes

No

Lavender

Yes

No

Yellow

Yes

No

Royal Blue

Yes

No

If not, why?

Unable
to collect

Medical
Reason

Spilled

Refused

Other

Unable
to collect

Medical
Reason

Spilled

Refuse

Other

Unable
to collect

Medical
Reason

Spilled

Refused

Other

Unable
to collect

Medical
Reason

Spilled

Refused

Other
22

If “other”, specify

[Free text Field]

[Free text Field]

[Free text Field]

[Free text Field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section K: Biological Specimen Collection – Finger Stick
K1. WAS A FINGER STICK CAPILLARY BLOOD SAMPLE COLLECTED?
YES ............. 1
NO ............... 2 [GO TO QUESTION K1c]
K1a. DATE OF CAPILLARY BLOOD SAMPLE
_____/_____/______ [MM/DD/YYYY]
K1b. TIME OF CAPILLARY BLOOD SAMPLE
__/__/: __/__/ [HH/MM] [GO TO QUESTION K2]
AM …….1
PM……..2
K1c. IF NO, PROVIDE A REASON
UNABLE TO COLLECT ..................................... 1 [GO TO SECTION L]
MEDICAL REASON .......................................... 2 [GO TO SECTION L]
EQUIPMENT MALFUNCTION .......................... 3 [GO TO SECTION L]
SPILLED ............................................................ 4 [GO TO SECTION L]
OTHER [FREE TEXT FIELD] ............................ 5 [GO TO SECTION L]
DON’T KNOW ................................................... 8 [GO TO SECTION L]
REFUSED ......................................................... 9 [GO TO SECTION L]
K2. RECORD HEMOGLOBIN A1C RESULT
__________%
K3. RECORD BLOOD LIPIDS RESULTS
Lipid Panel

Value

K3a.Total Cholesterol

________mg/dL

K3b. LDL Cholesterol

________mg/dL

K3c. HDL Cholesterol

________mg/dL

K3d. Triglycerides

________mg/dL

[PROGRAMMER NOTE: IF HEMOGLOBIN A1C AND LIPID RESULTS OBTAINED,
SHOW MESSAGE= REMEMBER TO GIVE PARTICIPANT HEMOGLOBIN A1C AND
LIPID RESULTS HANDOUT]

23

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section L: Biological Specimen Collection- Saliva Practice and Instruction
[PROGRAMMER NOTE: ONLY DISPLAY IF PARTICIPANT IS FLAGGED FOR AT
HOME SALIVA SAMPLE COLLECTION]
L1. WAS PARTICIPANT SELECTED FOR AT-HOME SALIVA SAMPLE
COLLECTION?
YES ............. 1
NO ............... 2 [GO TO SECTION M]
L2. DID PARTICIPANT AGREE TO COMPLETE AT-HOME SALIVA SAMPLE
COLLECTION?
YES ............. 1
NO ............... 2 [GO TO SECTION M]
L3. WAS A PRACTICE SALIVA SAMPLE OBTAINED?
YES ............. 1
NO ............... 2 [GO TO QUESTION L3c]
L3a.DATE OF PRACTICE SALIVA SAMPLE COLLECTION
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
L3b. TIME OF PRACTICE SALIVA SAMPLE COLLECTION
__ __: __ __ [HH/MM] [GO TO QUESTION L4]
AM .. 1
PM .. 2
L3c.IF NO, PROVIDE A REASON
MEDICAL REASON ............................... 1
OTHER ................................................... 2
DON’T KNOW ....................................... 8
REFUSED .............................................. 9
SPECIFY REASON [FREE TEXT FIELD] _______________

L4. AT-HOME SALIVA COLLECTION KIT ID
___I___II___II___I___II___I
[PROGRAMMER’S NOTE: REMIND CLINICIAN TO REVIEW AT-HOME SALIVA
COLLECTION INSTRUCTIONS]

24

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section M: Biological Specimen Collection – Urine
M1. WAS A MID-STREAM URINE SAMPLE COLLECTED DURING THE CLINICAL
EXAM VISIT?
YES ............. 1 [GO TO QUESTION M2]
NO ............... 2
[PROGRAMMER NOTE: SHOW MESSAGE=IF THE PARTICIPANT IS UNABLE TO
PROVIDE A URINE SPECIMEN, HAVE THEM DRINK A LARGE GLASS OF WATER,
SKIP THIS QUESTION FOR NOW AND RETURN TO IT LATER IN THE CLINICAL
VISIT WHEN THE PARTICIPANT IS ABLE TO PROVIDE A URINE SAMPLE.]
M1a. IF NO, PROVIDE A REASON
MEDICAL REASON ................... 1 [GO TO SECTION N]
UNABLE TO COLLECT ............... 2 [GO TO SECTION N]
EQUIPMENT MALFUNCTION .... 3 [GO TO SECTION N]
SPILLED ...................................... 4 [GO TO SECTION N]
OTHER ........................................ 5 [GO TO SECTION N]
DON’T KNOW ............................. 8 [GO TO SECTION N]
REFUSED ................................... 9 [GO TO SECTION N]
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER NOTE: SKIP OR SUPRESS ADDITIONAL URINE SAMPLE
QUESTIONS IF NO URINE WAS COLLECTED AND A REASON IS PROVIDED]
M2. VOLUME OF THE RANDOM URINE SAMPLE COLLECTED
__/__/__/ ML
M3. DATE OF RANDOM URINE SAMPLE
__/__/__ [MM/DD/YYYY]
M4. TIME THE RANDOM URINE SPECIMEN WAS COLLECTED.
__/__/: __/__/ [HH/MM]
YES ............. 1
NO ............... 2

25

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Leukocyte

Nitrite

Urobilinogen

Protein

pH

Blood

Specific
Gravity

Ketones

Billrubin

Glucose

Date

M5. RECORD URINE DIPSTICK RESULTS:

[MM/DD/
YYYY]

M6. WAS REMAINING URINE SAMPLE ALIQUOTTED FOR LONG TERM STORAGE
AND FUTURE ANALYSIS?
YES ............. 1 [GO TO QUESTION M7]
NO ............... 2
M6a. IF NO, PROVIDE A REASON
MEDICAL REASON ................... 1
UNABLE TO COLLECT ............... 2
EQUIPMENT MALFUNCTION .... 3
SPILLED ...................................... 4
OTHER ........................................ 5
DON’T KNOW ............................. 8
REFUSED ................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
M7. WAS PARTICIPANT SELECTED FOR QUALITY CONTROL URINE SPECIMEN?
YES ............. 1
NO ............... 2 [GO TO SECTION N]
M8. DID THE PARTICIPANT AGREE TO THE COLLECTION OF ADDITIONAL
QUALITY CONTROL URINE SPECIMENS?
YES ............. 1
NO ............... 2 [GO TO SECTION N]
M9. DID YOU COLLECT AN ADDITIONAL 40 mL OF URINE FOR QUALITY
CONTROL?
YES ............. 1 [GO TO QUESTION M10]
NO ............... 2
M9a. IF NO, PROVIDE A REASON
MEDICAL REASON ................... 1 [GO TO SECTION N]
UNABLE TO COLLECT ............... 2 [GO TO SECTION N]
EQUIPMENT MALFUNCTION .... 3 [GO TO SECTION N]
SPILLED ...................................... 4 [GO TO SECTION N]
26

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

OTHER ........................................ 5 [GO TO SECTION N]
DON’T KNOW ............................. 8 [GO TO SECTION N]
REFUSED ................................... 9 [GO TO SECTION N]
SPECIFY REASON [FREE TEXT FIELD] _______________
M10. VOLUME OF THE (QC) URINE SAMPLE COLLECTED
__/__/__/ ML
M11. DATE OF (QC) URINE SAMPLE
__/__/__[MM/DD/YYYY]
M12. TIME THE (QC) URINE SPECIMEN WAS COLLECTED.
__/__/: __/__/[HH/MM]
AM ........... …….1
PM .......... ……..2
M13. WAS REMAINING (QC) URINE SAMPLE ALIQUOTTED FOR LONG TERM
STORAGE AND FUTURE ANALYSIS?
YES ............. 1
NO ............... 2

27

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section N: Biological Specimen Collection- Hair
N1. WAS A HAIR SAMPLE COLLECTED?
YES ............. 1 [GO TO QUESTION N2]
NO ............... 2
N1a. IF NO, PROVIDE A REASON
NOT ENOUGH HAIR .................. 1 [GO TO SECTION O]
OTHER ........................................ 2 [GO TO SECTION O]
DON’T KNOW ............................. 8 [GO TO SECTION O]
REFUSED ................................... 9 [GO TO SECTION O]
SPECIFY REASON [FREE TEXT FIELD] _______________
N2. WERE THE PROXIMAL AND DISTAL ENDS OF THE HAIR
DESIGNATED/MARKED?
YES ............. 1
NO ............... 2
N2a. IF NO, PROVIDE A REASON
NOT ENOUGH HAIR .................. 1
OTHER ........................................ 2
DON’T KNOW ............................. 8
REFUSED ................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________

28

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section O: Biological Specimen Collection- Toenails
[PROGRAMMER NOTE: IF DIABETES=YES IN BACKGROUND SECTION, SKIP
ADDITIONAL TOENAIL QUESTIONS. SHOW MESSAGE= DO NOT COLLECT
TOENAILS; SKIP TO SECTION P]
O1. Are you currently wearing false toenails, nail tips, acrylic and or gel on your
toenails?
YES ............. 1 [GO TO QUESTION O4]
NO ............... 2
[PROGRAMMER NOTE: IS YES, DISPLAY MESSAGE = DO NOT ATTEMPT
TOENAIL COLLECTION; RECORD REASON FOR NOT COLLECTING SAMPLE AND
GIVE PARTICIPANT INSTRUCTIONS AND MAILING MATERIALS FOR TOENAIL
COLLECTION AT A LATER DATE]
O2. Are you currently wearing nail polish, nail hardener or any other nail product on
your toenails?
YES ............. 1
NO ............... 2 [GO TO QUESTION O3]
[PROGRAMMER NOTE: IF YES, DISPLAY MESSAGE = ASK PARTICIPANT IF THEY
ARE WILLING TO REMOVE NAIL PRODUCT(S) FROM TOENAILS; PROVIDE NAIL
POLISH REMOVER AND COTTON WIPE]
O2a. DID PARTICIPANT REMOVE NAIL POLISH, NAIL HARDENER OR ANY
OTHER NAIL PRODUCT USING NAIL POLISH REMOVER OR ACETONE?
YES ........................ 1
NO .......................... 2 [GO TO QUESTION O4]
O3. WERE TOENAIL SAMPLES COLLECTED?
YES ............. 1 [GO TO SECTION P]
NO ............... 2
O3a. IF NO, PROVIDE A REASON
NAILS NOT LONG ENOUGH ..... .......... 1
MISSING TOENAILS/TOES/FOOT ........ 2
MEDICAL CONDITION ............... .......... 3
OTHER ........................................ .......... 4
DON’T KNOW ............................. .......... 8
REFUSED ................................... .......... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER: SHOW ADDITIONAL FOLLOW UP QUESTIONS BELOW IF
TOENAIL SAMPLES WERE NOT COLLECTED AT VISIT AND REASON GIVEN]
29

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

O4. PARTICIPANT AGREED TO COLLECT AND SEND TOENAIL SAMPLES AT A
LATER DATE?
YES ............. 1
NO ............... 2

30

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section P: Biological Specimen Collection- Exhaled Breath Condensate (EBC)
P1. WAS EBC COLLECTED?
YES ............. 1
NO ............... 2 [GO TO QUESTION P1c]
P1a. DATE OF EBC COLLECTION
_____/_____/______ [MM/DD/YYYY]
P1b. TIME OF EBC COLLECTION
__/__/: __/__/ [HH/MM] [GO TO QUESTION P2]
AM …….1
PM……..2
P1c. IF NOT COLLECTED, PROVIDE A REASON
UNABLE TO COLLECT .......................... 1 [GO TO SECTION Q]
MEDICAL REASON ............................... 2 [GO TO SECTION Q]
EQUIPMENT MALFUNCTION ............... 3 [GO TO SECTION Q]
OTHER ................................................... 4 [GO TO SECTION Q]
REFUSED .............................................. 8 [GO TO SECTION Q]
SPECIFY REASON [FREE TEXT FIELD] _______________
P2. WAS AN ALIQUOT COLLECTED FOR LONG-TERM STORAGE?
YES ............. 1
NO ............... 2

31

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section Q: Neurobehavioral Test Battery
Q1. WAS ANY OF THE NEUROBEHAVIORAL TEST BATTERY (BARS COMPUTER
TESTS) COMPLETED?
YES ............. 1[GO TO QUESTION Q2]
NO ............... 2
Q1a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[GO TO Q5]
MEDICAL REASON .......................................................................... 2[GO TO Q5]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[GO TO Q5]
OTHER .............................................................................................. 4[GO TO Q5]
DON’T KNOW ................................................................................... 8[GO TO Q5]
REFUSED ......................................................................................... 9[GO TO Q5]
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER NOTE: IF NO OR REFUSED, SKIP NEUROBEHAVIORAL TEST
QUESTIONS]
Q2. RECORD DATE OF NEUROBEHAVIORAL TEST BATTERY
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
Q3. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
Q4. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
Q5. WAS TRAILMAKING TEST PERFORMED?
YES ............. 1 [GO TO QUESTION Q6]
NO ............... 2
Q5a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[GO TO R1]
MEDICAL REASON .......................................................................... 2[GO TO R1]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[GO TO R1]
OTHER .............................................................................................. 4[GO TO R1]
DON’T KNOW ................................................................................... 8[GO TO R1]
REFUSED ......................................................................................... 9[GO TO R1]
32

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

SPECIFY REASON [FREE TEXT FIELD] _______________
(PROGRAMMER NOTE: IF NO OR REFUSED, SKIP OR SUPRESS ADDITIONAL
TRAILMAKING TEST QUESTIONS)
Q6. RECORD DATE OF TRAILMAKING TEST
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
Q7. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
Q8. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
Q9. RECORD RESULTS FOR TRAILMAKING
Test

Score
obtained? Y/N

Score (in
seconds)

If no score obtained or
test refused, why?

Sample
practice test –
Trail A

Yes

No

Refused

I_I_I_I. I_I_I

Sample
practice testTrail B
Trailmaking
test A
Trailmaking
test B
Trailmaking
test A

Yes
No
Refused
Yes
No
Refused
Yes
No
Refused
Yes
No

Equipment
Malfunction
Medical Reason
Insufficient time to
complete
Examinee unable to
understand/follow
instructions
Ran out of
forms/supplies
Other

If other, specify;
Notes/comments

[Free text field]

I_I_I_I. I_I_I

“

”

[Free text field]

I_I_I_I. I_I_I

“

“

[Free text field]

I_I_I_I. I_I_I

“

“

[Free text field]

I_I_I_I. I_I_I

“

“

[Free text field]

33

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Refused

34

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section R: Peripheral Nerve Tests
(Source: Fred Gerr Instructions for measuring postural stability & BLSA)
R1. DID PARTICIPANT COMPLETE ANY PART OF THE PERIPHERAL NERVE TEST
BATTERY?
YES ............. 1 [GO TO QUESTION R2]
NO ............... 2
R1a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[GO TO R5]
MEDICAL REASON .......................................................................... 2[GO TO R5]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[GO TO R5]
OTHER .............................................................................................. 4[GO TO R5]
DON’T KNOW ................................................................................... 8[GO TO R5]
REFUSED ......................................................................................... 9[GO TO R5]
SPECIFY REASON [FREE TEXT FIELD] _______________
R2. DATE OF PERIPHERAL NERVE TEST BATTERY
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
R3. START TIME FOR PERIPHERAL NERVE TEST BATTERY
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R4. STOP TIME FOR PERIPHERAL NERVE TEST BATTERY
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
STANDING BALANCE TEST
SIDE BY SIDE STAND
R5. WAS SIDE BY SIDE STAND PERFORMED?
YES ............. 1 [GO TO QUESTION R6]
NO ............... 2
R5a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[GO TO R9]
MEDICAL REASON .......................................................................... 2[GO TO R9]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[GO TO R9]
OTHER .............................................................................................. 4[GO TO R9]
DON’T KNOW ................................................................................... 8[GO TO R9]
REFUSED ......................................................................................... 9[GO TO R9]
35

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

SPECIFY REASON [FREE TEXT FIELD] _______________
R6. RECORD RESULT(S) OF SIDE BY SIDE STAND
Outcome

Check
box
Participant refused
☐
Not attempted, unable
☐
Unable to attain position ☐
Unable to hold for 1 sec ☐
Holds for less than 10
☐
sec
Holds for 10 sec
☐

Notes/Comments
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

R7. START TIME FOR SIDE BY SIDE STAND
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R8. STOP TIME FOR SIDE BY SIDE STAND
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
SEMI-TANDEM STAND
R9. WAS SEMI-TANDEM STAND PERFORMED?
YES ............. 1 [GO TO QUESTION R10]
NO ............... 2
R9a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R13]
MEDICAL REASON .......................................................................... 2[JUMP R13]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R13]
OTHER .............................................................................................. 4[JUMP R13]
DON’T KNOW ................................................................................... 8[JUMP R13]
REFUSED ......................................................................................... 9[JUMP R13]
SPECIFY REASON [FREE TEXT FIELD] _______________
R10. RECORD RESULT(S) OF SEMI-TANDEM STAND
Outcome

Participant refused
Not attempted, unable

Check
box

☐
☐

Record
time in
sec.
N/A
N/A
36

Notes/Comments

[Free text field]
[Free text field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY
Unable to attain position
Unable to hold for 1 sec
Holds for less than 10 sec
Holds for 10 sec but < 30
sec
Holds for 30 sec

☐
☐
☐
☐
☐

N/A
N/A
I_I_I_I. I_I_I
I_I_I_I. I_I_I

N/A

[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

R11. START TIME FOR SEMI-TANDEM STAND
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R12. STOP TIME FOR SEMI-TANDEM STAND
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
[PROGRAMMER NOTE: IF “HOLDS FOR 10 SECONDS, BUT < 30 SECONDS” OR “HOLDS
FOR 30 SECONDS” DISPLAY INTERVIEWER NOTE= GO TO TANDEM STAND. IF “HOLDS
POSITION FOR LESS THAN 10 SECONDS” DISPLAY INTERVIEWER NOTE = GO TO 6
METER WALK]

TANDEM STAND
R13. WAS TANDEM STAND TRIAL 1 PERFORMED?
YES ............. 1 [GO TO QUESTION R14]
NO ............... 2
R13a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R17]
MEDICAL REASON .......................................................................... 2[JUMP R17]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R17]
OTHER .............................................................................................. 4[JUMP R17]
DON’T KNOW ................................................................................... 8[JUMP R17]
REFUSED ......................................................................................... 9[JUMP R17]
SPECIFY REASON [FREE TEXT FIELD] _______________
R14. RECORD RESULT(S) OF TANDEM STAND TRIAL 1
Outcome

Participant refused
Not attempted, unable
Unable to attain position
Unable to hold for 1 sec
Holds for less than 10 sec

Check
box

☐
☐
☐
☐
☐

Record
time in
sec.
N/A
N/A
N/A
N/A
I_I_I_I. I_I_I

37

Notes/Comments

[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY
Holds for 10 sec but < 30
sec
Holds for 30 sec

☐
☐

I_I_I_I. I_I_I

N/A

[Free text field]
[Free text field]

R15. START TIME FOR TANDEM STAND TRIAL 1
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R16. STOP TIME FOR TANDEM STAND TRIAL 1
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
[PROGRAMMER NOTE: IF “HOLDS FOR 10 SECONDS, BUT < 30 SECONDS” OR “HOLDS
FOR LESS THAN 10 SECONDS” DISPLAY INTERVIEWER NOTE= GO TO TANDEM STAND
TRIAL 2. IF “HOLDS POSITION FOR 30 SECONDS” DISPLAY INTERVIEWER NOTE = GO
TO ONE LEG STAND]

TANDEM STAND TRIAL 2
R17. WAS TANDEM STAND TRIAL 2 PERFORMED?
YES ............. 1 [GO TO QUESTION R18]
NO ............... 2
R17a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R21]
MEDICAL REASON .......................................................................... 2[JUMP R21]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R21]
OTHER .............................................................................................. 4[JUMP R21]
DON’T KNOW ................................................................................... 8[JUMP R21]
REFUSED ......................................................................................... 9[JUMP R21]
SPECIFY REASON [FREE TEXT FIELD] _______________
R18. RECORD RESULT(S) OF TANDEM STAND TRIAL 2
Outcome

Participant refused
Not attempted, unable
Unable to attain position
Unable to hold for 1 sec
Holds for less than 10 sec
Holds for 10 sec but < 30
sec
Holds for 30 sec

Check
box

☐
☐
☐
☐
☐
☐
☐

Record
time in
sec.
N/A
N/A
N/A
N/A
I_I_I_I. I_I_I
I_I_I_I. I_I_I

N/A

Notes/Comments

[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

38

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

R19. START TIME FOR TANDEM STAND TRIAL 2
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R20. STOP TIME FOR TANDEM STAND TRIAL 2
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
[PROGRAMMER NOTE: IF “HOLDS FOR 10 SECONDS, BUT < 30 SECONDS” OR “HOLDS
FOR LESS THAN 10 SECONDS” DISPLAY INTERVIEWER NOTE= GO TO 6 METER WALK.
IF “HOLDS POSITION FOR 30 SECONDS” DISPLAY INTERVIEWER NOTE = GO TO ONE
LEG STAND]

ONE LEG STAND TRIAL 1
R21. WAS ONE LEG STAND TRIAL 1 PERFORMED?
YES ............. 1 [GO TO QUESTION R22]
NO ............... 2
R21a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R25]
MEDICAL REASON .......................................................................... 2[JUMP R25]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R25]
OTHER .............................................................................................. 4[JUMP R25]
DON’T KNOW ................................................................................... 8[JUMP R25]
REFUSED ......................................................................................... 9[JUMP R25]
SPECIFY REASON [FREE TEXT FIELD] _______________
R22. RECORD RESULT(S) OF ONE LEG STAND TRIAL 1
Outcome

Participant refused
Not attempted, unable
Unable to attain position
Unable to hold for 1 sec
Holds for 1 sec but < 30
sec
Holds for 30 sec

Check
box

☐
☐
☐
☐
☐
☐

Record
time in
sec.
N/A
N/A
N/A
N/A
I_I_I_I. I_I_I

N/A

Notes/Comments

[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

R23. START TIME FOR ONE LEG STAND TRIAL 1
__ __:__ __ [HH/MM]
AM ............... 1
39

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

PM ............... 2
R24. STOP TIME FOR ONE LEG STAND TRIAL 1
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
[PROGRAMMER NOTE: IF “HOLDS FOR 1 SECOND, BUT < 30 SECONDS” DISPLAY
INTERVIEWER NOTE= GO TO LEG STAND TRIAL 2. IF “HOLDS POSITION FOR 30
SECONDS” DISPLAY INTERVIEWER NOTE = GO TO 6 METER WALK]

ONE LEG STAND TRIAL 2
R25. WAS ONE LEG STAND TRIAL 2 PERFORMED?
YES ............. 1 [GO TO QUESTION R26]
NO ............... 2
R25a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R29]
MEDICAL REASON .......................................................................... 2[JUMP R29]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R29]
OTHER .............................................................................................. 4[JUMP R29]
DON’T KNOW ................................................................................... 8[JUMP R29]
REFUSED ......................................................................................... 9[JUMP R29]
SPECIFY REASON [FREE TEXT FIELD] _______________
R26. RECORD RESULT(S) OF ONE LEG STAND TRIAL 2
Outcome

Participant refused
Not attempted, unable
Unable to attain position
Unable to hold for 1 sec
Holds for 1 sec but < 30
sec
Holds for 30 sec

Check
box

☐
☐
☐
☐
☐
☐

Record
time in
sec.
N/A
N/A
N/A
N/A
I_I_I_I. I_I_I

N/A

Notes/Comments

[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]
[Free text field]

R27. START TIME FOR ONE LEG STAND TRIAL 2
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
R28. STOP TIME FOR ONE LEG STAND TRIAL 2
__ __:__ __ [HH:MM]
AM ............... 1
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National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

PM ............... 2
POSTURAL STABILITY/STANDING STEADINESS TEST (SWAY)
R29. WAS POSTURAL STABILITY/STANDING STEADINESS TEST (SWAY)
PERFORMED?
YES ............. 1 [GO TO QUESTION R30]
NO ............... 2
R29a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1[JUMP R33]
MEDICAL REASON .......................................................................... 2[JUMP R33]
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3[JUMP R33]
OTHER .............................................................................................. 4[JUMP R33]
DON’T KNOW ................................................................................... 8[JUMP R33]
REFUSED ......................................................................................... 9[JUMP R33]
SPECIFY REASON [FREE TEXT FIELD] _______________
R30. DATE OF POSTURAL STABILITY/STANDING STEADINESS TEST (SWAY)
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
R31. START TIME OF POSTURAL STABILITY/STANDING STEADINESS TEST
(SWAY)
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
R32. STOP TIME OF POSTURAL STABILITY/STANDING STEADINESS TEST
(SWAY)
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
VIBROTACTILE THRESHOLD TEST
R33. WAS VIBROTACTILE THRESHOLD TEST PERFORMED?
YES ............. 1 [GO TO QUESTION R34]
NO ............... 2
R33a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
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REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
R34. RECORD DATE OF VIBROTACTILE THRESHOLD TEST
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
R35. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
R36. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
R37. RECORD RESULTS FOR VIBROTACTILE THRESHOLD TEST
Test

Dominant
great toe

NonDominan
t great
toe

Obtained? Y/N

In not obtained,
why?

st

1
down
value

I_I_I_I_I

I_I_I_I_I

Yes
No
Refused

st

1 up
value

I_I_I_I_I

I_I_I_I_I

Yes
No
Refused

nd

2
down
value

I_I_I_I_I

I_I_I_I_I

Yes
No
Refused

42

Equipment
malfunction
Medical
Reason
Examinee
unable to
understand/
follow
directions
Other,
specify
Equipment
malfunction
Medical
Reason
Examinee
unable to
understand/
follow
directions
Other,
specify
Equipment
malfunction
Medical
Reason
Examinee
unable to
understand/
follow
directions
Other,

If “other” reason
not collected,
specify. Enter
comments/notes

[Free Text Field]

[Free Text Field]

[Free Text Field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY
specify




nd

2 up
value

I_I_I_I_I

I_I_I_I_I

Yes
No
Refused

rd

3
down
value

I_I_I_I_I

I_I_I_I_I

Yes

No
Refused

Equipment
malfunction
Medical
Reason
Examinee
unable to
understand/
follow
directions
Other,
specify
Equipment
malfunction
Medical
Reason
Examinee
unable to
understand/
follow
directions
Other,
specify

[Free Text Field]

[Free Text Field]

R38. Do you normally wear or use reading glasses, contacts or something else to help
you see?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
R38a. If yes, are you wearing them or do you have them with you today?
YES .. ..................... 1
NO .... ..................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
VISUAL ACUITY TEST
R39. WAS VISUAL ACUITY TEST PERFORMED?
YES ............. 1
NO ............... 2
R39a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
43

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

SPECIFY REASON [FREE TEXT FIELD] _______________
R40. RECORD DATE OF VISUAL ACUITY TEST
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
R41. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
R42. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
R43. WERE RESULSTS OBTAINED?
YES ........................ 1
NO .......................... 2 [GO TO R43c]
R43a. RECORD RESULT-HIGHEST ROW WITHOUT ERROR (WITH VISION
CORRECTION: [__________]
R43b. RECORD RESULT-HIGHEST ROW WITHOUT ERROR (WITHOUT
VISION CORRECTION: [__________] [GO TO QUESTION R44]
R43c. IF RESULT NOT OBTAINED, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
CONTRAST SENSITIVITY TEST
R44. WAS CONTRAST SENSITIVITY TEST PERFORMED?
YES ............. 1 [GO TO QUESTION R45]
NO ............... 2
R44a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
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REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
R45. DATE OF CONTRAST SENSITIVITY TEST
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
R46. START TIME OF CONTRAST SENSITIVITY TEST
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
R47. STOP TIME OF CONTRAST SENSITIVITY TEST
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
R48. RECORD DATA FOR CONTRAST SENSITIVITY TEST

Test

Test
A
Limit

Test
B
Limit

Test
C
Limit

Test
D
Limit

Test
E
Limit

Enter
Limit
Value

Obtained? Y/N

If no or refuse, why?

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Yes
No
Refused

Medical reason
Examinee unable to
understand/follow
instructions
Other, specify
Medical reason
Examinee unable to
understand/follow
instructions
Other, specify
Medical reason
Examinee unable to
understand/follow
instructions
Other, specify
Medical reason
Examinee unable to
understand/follow
instructions
Other, specify
Medical reason
Examinee unable to
understand/follow
instructions
Other, specify

WALKING SPEED TEST AND LONG DISTANCE CORRIDOR WALK

45

If “other”,
specify enter
Comments/notes

[free text field]

[free text field]

[free text field]

[free text field]

[free text field]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

R49. Is there any reason you would feel unsafe or unable to complete the walking
tests?
YES ................................... 1
NO ..................................... 2 [GO TO QUESTION R50]
DON’T KNOW ................... 8 [GO TO QUESTION R50]
REFUSED ......................... 9 [GO TO QUESTION R50]
R49a. IF YES, SPECIFY [FREE TEXT FIELD] [GO TO SECTION S]
[PROGRAMMER NOTE: IF YES, SKIP SECTION; DO NOT ALLOW FOR FURTHER
DATA ENTRY]
[EXAMINER NOTE: THE FOLLOWING ARE EXCLUSION QUESTIONS FOR THE
LONG DISTANCE CORRIDOR WALK]
[PROGRAMMER NOTE: THE FOLLOWING ARE EXCLUSION QUESTIONS FOR THE
LONG DISTANCE CORRIDOR WALK. IF YES TO FOLLOWING QUESTIONS OR, IF
BP IS ≥180 SYSTOLIC AND OR 110 DIASTOLIC AND OR HR IS ≤ TO 40 BPM ≥ 120
SKIP THIS SECTION.]
R50. Will you need any walking aids or assistive devices such as crutches, a cane or
walker to help you complete the walking tests today?
YES ................................... 1[GO TO SECTION S]
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9
R51. In the past 3 months, have you had a heart attack or myocardial infarction?
YES ................................... 1 [GO TO SECTION S]
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9
R52. In the past 3 months, have you had an angioplasty or stent placement?
YES ................................... 1[GO TO SECTION S]
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9
R53. In the past 3 months, have you had heart surgery?
YES ................................... 1 [GO TO SECTION S]
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9
R54. Are you wearing shoes that make it difficult for you to walk?
46

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YES ................................... 1[GO TO SECTION S]
NO ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9

R55. RECORD RESULTS OF WALKING SPEED TEST
Attempt
1
[MM:SS]

Task

Attempt
2
[MM:SS]

Normal
Pace

Quick Pace

Between 20
centimeter
mark

Result(s)
obtained?

If no or other, specify

Yes
No
Refused
Other

[free text field]

Yes
No
Refused
Other

[free text field]

Yes
No
Refused
Other

[free text field]

R56. RECORD RESULTS OF LONG DISTANCE CORRIDOR WALK (400M)

Task

Record
result
[MM:SS]

Obtained?

47

If no, refused or other,
specify [comments]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

2 minute warm
up – first 20
seconds
400 Meters

Yes
No
Refused
Other
Yes
No
Refused
Other

48

[FREE TEXT FIELD]

[FREE TEXT FIELD]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section S: Hand/Grip Strength Test
S1. DID PARTICIPANT COMPLETE HAND/GRIP STRENGTH TEST?
Yes .............. 1[GO TO QUESTION S2]
No................ 2
S1a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER NOTE: IF NO OR REFUSED, SKIP THIS SECTION]
S2. DATE OF HAND/GRIP STRENGTH TEST
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
S3. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
S4. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
S5. Are you right handed, left handed, or do you use both hands equally to write with
and complete most other tasks?
Right handed ..................................................... 1
Left handed ....................................................... 2
Ambidextrous (Use both hands equally)........... 3
DON’T KNOW ................................................... 8
REFUSED ......................................................... 9

49

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

S6. RECORD DYNAMOMETER (HAND/GRIP STRENGTH) RESULTS

Trial #

1

2

Result
Obtained?

3

Dominant
Hand Grip
(kg)
NonDominant
Hand Grip
(kg)

50

Yes
No
Refused
Other
Yes
No
Refused
Other

If no, refused or
other, specify
(comments/notes)
[FREE TEXT
FIELD]

[FREE TEXT
FIELD]

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section T: Exhaled Nitric Oxide (eNO)
T1. WAS TEST FOR EXHALED NITRIC OXIDE COMPLETED?
Yes .............. 1 [GO TO QUESTION T2]
No................ 2
T1a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER NOTE: IF NO OR REFUSED, SKIP OR SUPRESS ADDITIONAL
EXHALED NITRIC OXIDE TEST QUESTIONS]
T2. RECORD DATE EXHALED NITRIC OXIDE TEST PERFORMED
__ __/__ __/__ __ __ __ [MM/DD/YYYY]
T3. RECORD START TIME
__ __: __ __ [HH:MM]
AM ............... 1
PM ............... 2
T4. RECORD STOP TIME
__ __:__ __ [HH:MM]
AM ............... 1
PM ............... 2
T5. HOW MANY TOTAL MANUEVERS/ATTEMPTS WERE PERFORMED?
[EXAMINER NOTE: NO MORE THAN 8 TOTAL MANUEVERS/ATTEMPTS SHOULD
BE PERFORMED]
I_I_I
T6. Within the last hour, have you smoked a cigarette, cigar, pipe, or used any other
tobacco product?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9

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National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

T7. Within the last hour, have you done any vigorous or strenuous exercise?
Vigorous or strenuous exercise requires hard physical effort and often times leads to
heavy breathing and a faster heartbeat.
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
T8. Within the last hour, have you had anything to eat or drink?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
T9. Within the last 3 hours have you eaten beets, broccoli, cabbage, celery, lettuce,
spinach, radishes or root vegetables?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
T10. Within the last 3 hours have you eaten bacon, ham, hot dogs, or smoked fish?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
T11. Within the past 2 days have you used any oral or inhaled steroids? (I.e. inhaled
glucocorticoids and montelukast)?
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9
T12. In the past 7 days, have you had a cough, cold, airway infection, respiratory
illness, phlegm or runny nose? Do not count allergies or hay fever.
YES ............. ..................... 1
NO ............... ..................... 2
DON’T KNOW ................... 8
REFUSED ... ..................... 9

52

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section U: Exhaled Breath Condensate Test (EBC)
U1. WAS EBC PROCEDURE COMPLETED?
YES ............. 1 [GO TO QUESTION U2]
NO .............. 2
U1a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
EXAMINEE UNABLE TO UNDERSTAND/FOLLOW DIRECTIONS .. 3
OTHER .............................................................................................. 4
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
[PROGRAMMER NOTE: IF NO OR REFUSED, SKIP ADDITIONAL EXHALED NITRIC
OXIDE TEST QUESTIONS]
U2. DATE OF EBC PROCEDURE/COLLECTION
__/__/__ [MM/DD/YYYY]
U3. START TIME OF EBC COLLECTION
__ __:__ __ [HH/MM]
AM ............... 1
PM .............. 2
U4. STOP TIME OF EBC COLLECTION
__ __:__ __ [HH/MM]
AM ............... 1
PM .............. 2
U5. TOTAL TIME FOR EBC COLLECTION
__ __:__ __ [MM:SS]

53

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section V: Pulmonary Function Testing (PFT)
[PROGRAMMER NOTE: IF THE AVERAGE SYSTOLIC BP ≥ 180 OR DIASTOLIC BP ≥
110 OR HEART RATE ≤ 40 OR ≥ 120, OR INDICATED THAT PARTICIPANT IS
FEMALE AND PREGNANTSKIP PULMONARY FUNCTION TEST.]
[PROGRAMMER NOTE: THE FOLLOWING QUESTIONS ARE EXCLUSION
CRITERIA FOR PULMONARY FUNCTION TESTING. IF “YES”, “DON’T KNOW” OR
“REFUSED” TO ANY OF THE FOLLOWING QUESTIONS (Q-Q), SKIP PULMONARY
FUNCTION TEST.]
V1. During the past 24 hours, have you used a short-term or long-acting
bronchodilator?
YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V2. In the past three months, have you had any surgery to your chest or abdomen?
YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V3. In the past three months, have you had a heart attack or stroke?
YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V4. In the past three months, have you had a detached retina or eye surgery?
YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V5. In the past three months, have you been hospitalized for any other heart problem?
YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V6. Are you currently taking medication for tuberculosis?
54

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

YES ............. ..................... 1 [GO TO SECTION W]
NO ............... ..................... 2
DON’T KNOW ................... 8 [GO TO SECTION W]
REFUSED ... ..................... 9 [GO TO SECTION W]
V7. DID PARTICIPANT COMPLETE PULMONARY FUNCTION TESTING (PFT)?
YES ............. 1 [GO TO QUESTION V8]
NO ............... 2
V7a. IF NO, PROVIDE A REASON
EQUIPMENT MALFUNCTION .......................................................... 1
MEDICAL REASON .......................................................................... 2
OTHER .............................................................................................. 3
DON’T KNOW ................................................................................... 8
REFUSED ......................................................................................... 9
SPECIFY REASON [FREE TEXT FIELD] _______________
V8. DATE OF PFT PROCEDURE
__/__/__ [MM/DD/YYYY]
V9. TIME OF PRE-SPIROMETRY BRONCHODILATION (ALBUTEROL)
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2
V10. TIME OF POST-SPIROMETRY BRONCHODILATION (ALBUTEROL)
__ __:__ __ [HH/MM]
AM ............... 1
PM ............... 2

55

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section W: Medical Referrals
W1. WAS A MEDICAL REFERRAL PROVIDED?
YES ............. 1
NO ............... 2
W1a. IF YES, HOW MANY REFERRALS WERE PROVIDED?
|_||_| NUMBER OF REFERRALS
[PROGRAMMER NOTE: LOOP THROUGH “REASON FOR REFERRAL” FOR
EACH REFERRAL PROVIDED/INDICATED]
W1b. REASON FOR REFERRAL:
MENTAL HEALTH PROBLEM(S).................................................................1
MEDICAL PROBLEM(S) ..............................................................................2
SOCIAL PROBLEM (HOMELESSNESS, ALCOHOL/DRUGS, ETC) ...........3
OTHER, SPECIFY [FREE TEXT FIELD] ......................................................4

56

National Institute of Environmental Health Science (NIEHS) Version 2.0 (07/19/2013) GuLF STUDY

Section X: Check-Out, Review and Remuneration
X1. DID PARTICIPANT RECEIVE GIFT CARD(S) FOR REMUNERATION?
YES ............. 1 [GO TO QUESTION X2]
NO ............... 2
X1a. PROVIDE REASON: [FREE TEXT FIELD] [END OF EXAM]
X2. IF YES, ENTER ID NUMBER(S)
ID # __ __ __ __
ID # __ __ __ __
ID # __ __ __ __
[END OF EXAM]

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