SEARCH Pathology Notificaiton (Retinal Photo)

Form Approved 
OMB No. 0920‐xxxx 
Exp. Date xx/xx/xxxx 

SEARCH Pathology Notification
Subject ID# ___ ___ ___ ___ ___ ___ ___ ___
Photo date ___/ ___/ ___
Grader ________

Eye

OD

Grade date ___/ ___/ ___

OS
Early

Immediate

Please check any lesions or conditions present that may require further evaluation:
Active Proliferative Retinopathy ____
NVD
___
NVE
___ circle fields 1
PRH
___ circle fields 1
VH
___ circle fields 1
ret detach
___ circle fields 1
scatter/local rx
___

2
2
2
2

Preproliferative Retinopathy ____
VB
___ circle fields 1 2
significant IRMA
___ circle fields 1 2
significant HMA
___ circle fields 1 2
Macular Edema
____
Edema, not CSME ____
CSME
____
focal/grid rx
____
Other

____
irregular nevus
recent BVO/CVO
large cup/disc ratio
other

___
___
___
___

circle fields 1 2

Comments
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Request for Additional Information
______________________________________________________________________
____________________________________________________________________
_____________________________________________________________________
e-mailed __/__/__ _____
Reading List # ____
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 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐xxxx). 
SEARCH 3 Cohort Study - Retinal Photo - 11-01-10

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