Attachment 1A Annual Form

SISOMB2016 ATTACHMENT 1A: ANNUAL UPDATE FORM
SIS «StudyID»

FORM: 23

VERS: 01

OMB No. 0925-0522

Contact Information Update Form
Please return this form even if there are no changes to report.

Help us keep in touch with you by reporting changes to your contact information. If you’ve moved, are about to
move, or changed your phone number or email address, please provide your updated information.
Today’s date:

/ 2 0

/
(month)

(day)

(year)

There have been no changes to any of my contact information. (Check box and go to next page.)
Name and Primary Address

Update or Correction

Name: «FirstName»
«MiddleInitial»
«LastName»
If you have more than one residence, provide information for your primary address, where you live most of the year.

Street Address: «Address1»
«Address2»
,

«City», «State»
-

«Zip»
If you have moved, what was the date of your move? OR,
If you are moving in 2-3 months, what date will you move?

(month)

Mailing Address:

Same as street address

/

(day)

/

2 0
(year)

«Address1»
«Address2»
,

«City», «State»
-

«Zip»
Telephone Numbers We Can Use to Reach You:
Home phone: «HomePhoneNumber»

(

)

-

Work phone: «WorkPhoneNumber» «WorkPhoneExt»

(

)

-

Cell phone: «OtherPhoneNumber»

(

)

-

ext.

Email Address We Can Use to Reach You:
Email: «Email1»

@

.

PAGE ONE - PLEASE CONTINUE TO NEXT PAGE
ID#: SIS

*«StudyID»-spec*

National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services

Please return this form even if there are no changes to report.

We request the names of two people who do not live with you, but who will always know
how to reach you. Please be sure their information is up to date. You may replace a contact
person with someone else by filling in the new information. If we do not have two contacts
for you, please provide the information below.
There have been no changes to any of the information for my contact people. (Check box and return form.)
First Contact

Update/Correction/New Contact

Name: «FirstName»
«LastName»
Relationship to you: «Relationship»
Address: «StreetNumber» «StreetName»
«ApartmentNumber»
,

«City», «State»
-

«Zip»
Phone Number: «PhoneNumber»

(

What is the reason for the changes you made?

-

)

updating old or outdated information
correcting errors in current information
replacing old contact with a new contact person

Second Contact

Update/Correction/New Contact

Name: «FirstName»
«LastName»
Relationship to you: «Relationship»
Address: «StreetNumber» «StreetName»
«ApartmentNumber»
,

«City», «State»
-

«Zip»
Phone Number: «PhoneNumber»
What is the reason for the changes you made?

(

)

-

updating old or outdated information
correcting errors in current information
replacing old contact with a new contact person

After completing both pages of this form, please mail it to the address below. A postage-paid envelope is
provided. Thank you!

The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]

National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services

FORM: 60

VERS: 03 OMB No. 0925-0522

Sister Study Health Update: Year 7
* Please fill out this form even if there are no changes to report. *
It is important to the Sister Study that we stay updated on your health. Please take a few minutes
to fill out this form and let us know if you have been diagnosed with any of the following conditions
since August 2012.

/

Today’s date
month

/
day

ID #

*«StudyI

year

«StudyID»
1. Since August 2012, has a doctor or other health professional told you that you had any of the following
conditions?
If YES, give the month and year of diagnosis.

Please mark No or Yes for each question.
NO

YES

MONTH / YEAR

a

Breast cancer

aa

Aa

aa aa / a2a a0a aa aa

b

DCIS (ductal [breast] carcinoma in situ)

aa

Aa

aa aa / a2a a0a aa aa

c

LCIS (lobular [breast] carcinoma in situ)

aa

Aa

aa aa / a2a a0a aa aa

d

Lung cancer

aa

Aa

aa aa / a2a a0a aa aa

e

Ovarian cancer

aa

Aa

aa aa / a2a a0a aa aa

f

Cancer of the uterus or endometrium (please do
not include non-cancerous conditions
such as fibroids, endometriosis, or pre-cancer)

aa

Aa

aa aa / a2a a0a aa aa

g

Cancer of the colon or rectum

aa

Aa

aa aa / a2a a0a aa aa

h

Melanoma

aa

Aa

aa aa / a2a a0a aa aa

i

Any other type of cancer except non-melanoma
skin cancer

aa

Aa

aa aa / a2a a0a aa aa

j

Heart attack (myocardial infarction – MI)

aa

k

Other heart disease (e.g. angina, congestive
heart failure, arrhythmias)

aa

l

Stroke, mini-stroke, TIA

aa

m

Thyroid disease (e.g. Graves’ disease, overactive
thyroid/hyperthyroidism, thyroiditis, underactive
thyroid/hypothyroidism, or other)

What kind?
a a

aa aa / a2a a0a aa aa

Were you a patient in a hospital overnight? NO A a YES a a
Aa

What kind?

aa

_______________________________

aa aa / a2a a0a aa aa
_______________________________

Aa

aa aa / a2a a0a aa aa

Aa

aa aa / a2a a0a aa aa

What kind?
Aa

_______________________________
aa aa / a2a a0a aa aa

n

Autoimmune disease (e.g., rheumatoid arthritis,
lupus, scleroderma, multiple sclerosis, or other)

aa

o

Parkinson’s disease

aa

Aa

aa aa / a2a a0a aa aa

p

Hypertension (high blood pressure)

aa

Aa

aa aa / a2a a0a aa aa

q

Diabetes

aa

Aa

aa aa / a2a a0a aa aa

r

Hip, wrist or other fracture

Aa

aa aa / a2a a0a aa aa

aa

s

Any other major illness

aa

What kind?

What kind?
Aa

What kind?

_______________________________

_______________________________
aa aa / a2a a0a aa aa
_______________________________

PLEASE CONTINUE ON THE BACK
U.S. Department of Health and Human Services / National Institutes of Health / National Institute of Environmental Health Sciences

FORM: 60

VERS: 03 OMB No. 0925-0522

2. Have you gone through menopause?
No
Don’t Know
Yes

3. What month and year did you have your last menstrual period or how old were you when you had your last
menstrual period?
/
MONTH

.

OR

YEAR

AGE

4. Have you ever smoked at least one cigarette per day for six months or longer?
No  GO TO QUESTION 7
Yes

5. What best describes your smoking status?
Stopped smoking cigarettes
Currently smoking cigarettes

6. During the years you smoked, how many cigarettes do/did you usually smoke per day?
Less than one pack per day
One pack per day
More than one pack per day

7. Are you currently using hormones for hormone replacement (HRT)? Please include pills and patches. Common
brand and generic names are Prempro, Premarin, Estrace, estradiol, Provera, medroxyprogesterone, etc.
No
Yes
Thank you for your continued participation in the Sister Study. Please mail this form to:
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703. A postage-paid envelope is provided.
Phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]
Public reporting burden for this collection of information is estimated to average 10 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 (0925-0522). Do not return the completed form to this address.

U.S. Department of Health and Human Services / National Institutes of Health / National Institute of Environmental Health Sciences