Form 1 Annual Study Update (ASU)

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
ANNUAL STUDY UPDATE and Follow-Up-Form (ASUFLF)

OMB No.: 0925-0407
Expires: XX/XX/XXXX

PRIVACY ACT NOTIFICATION STATEMENT
Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a1). Rights of study participants are protected by the Privacy Act of 1974. Participation is voluntary, and
there are no penalties for not participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The information collected in this study will be held
in professional confidence. Names and other identifiers will be separated from information provided
and will appear in any report of the study. Information provided will be combined for all study
participants and reported as statistical summaries.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 5 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
mat not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925-0407). Do not return the completed form to this address.

Version Date: 7/2006
Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
FOLLOW-UP LOCATOR FORM

Participant ID:
Study Year:

804104-8
T16 / C

Today's Date:

/

*804104-8*
*804104-8*

May 22, 2012

/

Please review the information printed in the left column below to make sure it is correct.
If the information in the left column is correct, check the 'OK' box. Make any additions or corrections
in the right column.

FULL NAME:
Str. ALBERTINE MARGARITA Wiles R.M.

OK

FULL NAME:

OTHER LAST NAMES:
SHELLY
KALEIGH
NICKNAME/PREFERRED NAME:

OK

OTHER LAST NAMES:

OK

NICKNAME / PREFERRED NAME:

MAIDEN NAME: Arlow

OK

MAIDEN NAME:

OK

DATE OF BIRTH:

OK

HOME ADDRESS/PHONES:

DATE OF BIRTH:

5/19/1934

12:00:00AM

CURRENT HOME ADDRESS:
RT 1 BOX 354
3221 GLENDALE AVE
Hopwell
PA
15216
(414)953-4612
Work Phone: (414)280-8025
Cell Phone:
Email Address:

Home Phone:

VACATION HOME/OTHER RESIDENCE:
2095 ROYAL OAK AVE
W4914 ED SEVERSON RD
London, England
Phone: (414)427-8614
Time of Year:

Home Phone:
Extension

Work Phone:
Cell Phone:
Email Address:

OK

Ext:

VACATION/OTHER ADDRESS/PHONE:

Phone:
Time of Year:

Page 3 of 8

Participant ID: 804104-8

Study Year:

T16 / C

*804104-8*
*804104-8*

ADULT HOUSEHOLD MEMBERS:

ADULT HOUSEHOLD MEMBERS:

Name:

Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Jessie Caroline Gawlak
Spouse
Relationship:

Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:

Page 4 of 8

Participant ID: 804104-8

Study Year:

*804104-8*
*804104-8*

T16 / C

PRIMARY CARE PHYSICIAN/CLINIC:

PRIMARY CARE PHYSICIAN/CLINIC:

Allen M. Golden
333 Medical Rd
333 Professional Dr
City
CO
00000

OK

(000)000-0000
000
Physician Type: Primary Doctor

Phone
:
Fax:

Phone:
Fax:

Physician Type:

Solomon Raymond Fife
710 18th St
721 W Jackson St
Smithfield
PA
15219
Phone:

OK

(414)492-6310

Phone
:
Fax:

Fax:

Physician Type:

Primary Doctor

Physician Type:

Anacletus Jacob Agnello
Po Box 107
12046 Cty Tr V
Gary
PA
15213
Phone:

OK

Phone
:
Fax:

(414)879-8111

Fax:

Physician Type:

Primary Doctor

Physician Type:

Anzy Petro Agar
6587 Deer Path Rd
N5387 Willow Rd
Mckeesport
PA
15963
Phone:

OK

Phone
:
Fax:

(414)526-2386

Fax:

Physician Type:

Primary Doctor

Physician Type:

Angeline Peter Adrian
500 Water St
1220 Township Ave
Puerto Rico
PA
15235
Phone:

Fax:

Primary Doctor

Annetta Algart Adametz
Continental Manor
5044 N Biron Dr
Jenner Twp. Somerset Co.
Phone:

OK
PA

15135
Phone
:
Fax:

Primary Doctor

Alverda Jeanine Acton
21897 Spirit Lk Rd W
413 Main
Louisville
PA
15143
Phone:

Physician Type:

(414)913-2769

Physician Type:

Fax:

Phone
:
Fax:

(414)713-7975

Physician Type:

Fax:

OK

(414)547-6350

Physician Type:
OK

Phone
:
Fax:

Page 5 of 8

Participant ID: 804104-8

T16 / C

Study Year:

*804104-8*
*804104-8*

PRIMARY CARE PHYSICIAN/CLINIC:
Physician Type:
Aldo Georgine
N15318 Cty Rd
3811 Griffith
Farrel
PA
Phone:

PRIMARY CARE PHYSICIAN/CLINIC:

Primary Doctor

Acheson
O
Ave
16117

Physician Type:
OK

(414)863-8579

Phone
:
Fax:

Fax:

Physician Type:

Primary Doctor

Ahmed Vincent Abbruzzese
5554 Easy St
663 S Waupaca Apt 5
Juniata
PA
15650
Phone:

Physician Type:
OK

(414)609-9902

Phone
:
Fax:

Fax:

Physician Type:

Primary Doctor

Aldo Walter Abbondanza
Po Box 394
930 16th St N
Gibsonia
PA
15226
Phone:

Physician Type:
OK

Phone
:
Fax:

(414)986-7058

Fax:

Physician Type:

Primary Doctor

Al Viola Adam
1420 Woodbine
Rt 1, Box 304
Shreveport
AK
Phone:

OK

(414)299-8321

Fax:

Physician Type:

Physician Type:

Primary Doctor

Phone
:
Fax:

Physician Type:

Page 6 of 8

Participant ID: 804104-8

Study Year:

T16 / C

*804104-8*
*804104-8*

In the past, you provided us with the names and addresses of the following people who could give us
your new address if you move. It is helpful for us to get the names of people who do not live with
you. Please confirm that these people are the best contacts for you.

CONTACTS:
Fruma Floretta Colker
N790 S German Settlement Rd
N8033 E Wilson Flowage Rd
Houtzdale
PA
15216
(414)303-1537
Phone 1:
Phone 2:

CONTACTS:
OK

Phone 1:
Phone 2:

Email Address:

Relationship:

Type:
Type:

Email Address:

Son

Relationship:
OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Harrison Miklos Toberman
1607 E Doege St
N3167 Hwy 40
Vadergrift
HI
96825
(414)658-4780
Phone 1:
Phone 2:

OK

Phone 1:
Phone 2:

Email Address:

Relationship:

Type:
Type:

Type:
Type:

Email Address:

Daughter

Relationship:
OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

Page 7 of 8

Participant ID: 804104-8

Study Year:

T16 / C

*804104-8*
*804104-8*

In the past, you provided us with the names and addresses of the following people who could give us
your new address if you move. It is helpful for us to get the names of people who do not live with
you. Please confirm that these people are the best contacts for you.

CONTACTS:

CONTACTS:
OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

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

Page 8 of 8