Liver Ultrasound

Attachment A2

National Health and Nutrition Examination Survey (NHANES)

Liver Ultrasound Elastography Pilot Study

Data Collection Form

OMB no. 0920-0950

Expires: 11/30/2016

Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden of this collection of information is estimated to average 15 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0950).

Hepatic (liver) Steatosis and Fibrosis Ultrasound Elastography (ages 12 year and older) Form

SP ID______________ Tech ID_______________

HEPATIC (liver) STEATOSIS TEST RESULTS

Test complete Yes No

Test result for median controlled attenuation parameter (CAP™) ____ decibel per meter, (dB/m)

REASONS TEST INCOMPLETE OR NOT DONE

Physical limitation

SP refusal

SP ill/emergency

Out of time

Equipment failure

Communication problem

HEPATIC (liver) FIBROSIS TEST RESULTS

Test complete Yes No

Test result for median Young’s Modulus (E) __________ kilopascals

REASONS TEST INCOMPLETE OR NOT DONE

Physical limitation

SP refusal

SP ill/emergency

Out of time

Equipment failure

Communication problem