5 Safety Screen

OMB#: 0925-XXXX

Exp. XX/XXXX

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 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-XXXX). Do not return the completed form to this address.

OMB#: 0925-XXXX

Exp. XX/XXXX

H CHS/ SOL Participant Scheduling and Screening

ID NUMBER:

FORM CODE: PSE VERSION: A 8/28/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date (mm/dd/yyyy): //

0b. Staff ID:

Instructions: This screening form must be completed before the participant can be seen in clinic for their Baseline Examination. Responses are noted on the Exam Itinerary Checklist for routing purposes.

Am I talking to: _(name of eligible HH resident, recruited or being recruited)_?

How old are you?

(And) you are Hispanic/Latino, correct ?

Do you have any plans to move away from this area in the next 6 months?

No (0)

Yes (1) Probe to see how far away 

If still eligible, proceed to schedule a time to come into the field center. Record date and time of appointment in the local tracking and scheduling system.

A. Safety and Eligibility Screening Questions

I need to ask you a few questions as I schedule your visit to the HCHS/SOL clinic.

1. Are you pregnant (FEMALES only)?

No (0)

Yes (1) STOP, Reschedule Visit after delivery 

3. Do you need any kind of assistance in getting on an examination table, to read, or to hear questions from an interviewer? No (0)

Yes (1) GO to 3a 

4. Do you have a heart pacemaker or defibrillator?

No (0)

Yes (1) Exclude from BIA measurement 

5. Has a doctor or health professional ever told you that you have diabetes

(high sugar in blood or urine)? No (0)

Yes (1) Exclude from OGTT 

B. Periodontal Exam Exclusion Questions

A YES response to any of the questions that follow will Exclude the participant from the Periodontal portion of the Dental Examination, note on exam itinerary form.

7. Do you have artificial valves in your heart?

No (0)

Yes (1) Periodontal Exam Exclusion 

8. Have you been treated by a physician for infective endocarditis?

No (0)

Yes (1) Periodontal Exam Exclusion 

9. Do you have a serious heart condition from birth?

No (0)

Yes (1) Periodontal Exam Exclusion 

10. Have you had a heart transplant?

No (0)

Yes (1) Periodontal Exam Exclusion 

11. Do you have artificial joints or protheses?

No (0)

Yes (1) Periodontal Exam Exclusion 