Form 2 Proxies

OMB #0925-0493 Exp: XX/XXXX

Multi-Ethnic Study of Atherosclerosis

Participant ID: 8000028

02

Sequence Num:
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 0925-0493. Do not
return the completed form to this address.

Informant Interview

Where there is a blank ( ) in the text of a question, insert the name of the participant.
Date of
/
/
Death:
Month

Day

Informant Information

Year

3. Was anyone present when s/he died?
Yes

1a. Relationship of informant to deceased:
Spouse

No

Unknown
If "Yes," skip to Question 6.

Daughter/Son

4. Was anyone close enough to hear ( ) if s/he had
called out?

Parent
Friend

Yes

Workmate

No

Unknown

5. How long was it between the time ( ) was last known
to be alive and the time s/he was found dead?

Other Relative:

Less than 5 minutes
Other:

5 minutes to 1 hour
1 to 24 hours
Longer than 24 hours

1b. Name of informant (for interviewer use):

Unknown

6. Please tell me who was present:

Circumstances Surrounding Death

Self

I would like to ask you about the circumstances
surrounding ( )'s death. If you have any questions as we
go along, please ask me.
2. Please tell me about his/her general health, health on
the day s/he died, and about the death itself.
Record a brief synopsis of the events surrounding the death as
related by the informant. Append a typed copy of this account to
this questionnaire.

Skip to Question 7.

Nursing staff, physician or paramedic
Other lay person
If "Self," skip to Question 8.

7. When was the last time you saw ( ) prior to his/her
death?
Less than 5 minutes
5 minutes to 1 hour
1 to 24 hours

Some of the remaining questions may repeat information
already provided, but it helps us to ask these items
specifically.

Longer than 24 hours
Unknown

3196209437
11/09/2004

page 1 of 3

Informant Interview (Page 2)

8000028
History

02

Symptoms

The next few questions concern ( )'s medical history.
8. Was s/he restricted to home, able to leave home only
with assistance or great effort, or was his/her activity
unrestricted?

The next set of questions deals specifically with acute
symptoms such as pain, discomfort or tightness that ( )
may have experienced at the time of his/her death (i.e.,
starting at the time s/he noticed the symptoms that
caused him/her to stop or change what s/he was doing).

Restricted to home
Able to leave home only with assistance or great
effort

13. Did s/he experience pain, discomfort or tightness in
the chest, left arm or jaw?

Unrestricted

Yes

9. Was s/he hospitalized within the four weeks prior to
death?
Yes

No

Unknown

If "No" or "Unknown," skip to Question 20.

Unknown

If "No" or "Unknown," skip to Question 12a.

14. Did the pain, discomfort or tightness specifically
involve the chest?
Yes

10. What was the reason for the hospitalization?
Coronary heart disease, heart attack, angina, or
cardiac arrest
Cerebrovascular disease or stroke

No

No

Unknown

15. Were these episodes new, or had they occurred
previously?
New symptoms

Other cardiovascular disease

Previous symptoms

Other non-cardiovascular disease

Unknown

Heart surgery

If "New symptoms," skip to Question 20.

Other surgical procedure(s)

16. Were the episodes getting longer or more frequent?

Diagnostic procedure(s)

Yes

No

Unknown

Other:
17. Were the episodes getting more severe?

Unknown

Yes

11a. What was the date of the hospital admission?

/
Month

/
Day

Year

11b. What was the name and location of the hospital?

No

Unknown

If "No" or "Unknown," to Questions 16 and 17,
skip to Question 19.

18. Over what period of time did these episodes become
longer, more frequent, or more severe?
Days
Weeks
Months

12a. Was ( ) seen by a physician at any other time in
the last four weeks prior to death?
Yes

No

Unknown

If "No" or "Unknown," skip to Question 13.

Unknown
19. You may not be able to answer this: How long was it
from ( )'s last episode of symptoms to the time that s/he
stopped breathing on his/her own?

12b. What is the name and address of this physician?

Less than 5 minutes
Less than 1 hour
Less than 24 hours
Greater than 24 hours
Unknown
6033209430

11/09/2004

page 2 of 3

Informant Interview (Page 3)

8000028

02

Emergency Medical Care
20. Was ( ) taken to the hospital, emergency room, or
any other emergency care facility ?
Yes

No

24. What is your rating of reliability of the interview?

Unknown

21. Is there anyone else we could contact who might
be able to provide additional information about the
circumstances surrounding ( )'s death or his/her usual
state of health?
Yes

Reliability

No

Unknown

Good
Fair
Poor

Notes

If "No" or "Unknown," skip to "Closing Script."

22. How is s/he related to the deceased?
Spouse
Daughter/Son
Parent
Friend
Workmate
Other Relative:

Other:

23. What is the name and address of this person?

Closing Script: Thank you very much for your
assistance in this important study. Do you have
any questions? (Pause, and continue if there are
no questions.) Thanks again for your help.

/
Month

/
Day

Interviewer ID:

Year

Data Entry ID:
2372209432

11/09/2004

page 3 of 3

8000028 02

Multi-Ethnic Study of Atherosclerosis

Seq. Num

Informant Interview Narrative

INFNOT

/
Month

/
Day

Year

Interviewer ID:
1762630511

12/13/2001

page 1 of 1

OMB #0925-XXXX Exp: XX/XX/XXXX

8000028 02

Multi-Ethnic Study of Atherosclerosis

Page Num

Cardiac/PVD Interview

CARINT

This form should be used if there is insufficient information from hospital, physician or other records/forms to classify
the cardiac event. The purpose is to obtain a narrative of events surrounding the event to supplement data already
collected.
We are calling today from the MESA Clinical Center at (
). We understand that you had a diagnosis
of (MI/angina/CHF/PVD) on (date). To help us complete our records, could you please tell us more about
this? For example: What were you doing when symptoms started? What were your symptoms? How
long did they last? What happened? Did you see a physician? What was done? Please describe what
happened in your own words.
Probe for details regarding symptoms and their duration; ask about chest, arm, and jaw pain specifically if not
volunteered.
Narrative:

/
Month

/
Day

Year

Interviewer ID:
7590168196

02/25/2002

page 1 of 1

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

E.2

Sample MESA Events Letters

E.2.1

HOSPREL (Hospital medical record release form)

Appendix E, Page

2

MESA STUDY HOSPITAL MEDICAL RECORD RELEASE FORM

Patient:

[participant name]
[participant street address]
[participant city, state zip]

Hospital:

[hospital name]
[hospital street address]
[hospital city, state zip]

Please release to the Multi-Ethnic Study of Atherosclerosis (MESA):
All records of hospitalizations which occurred during the period [time between clinic
visit and follow-up phone call 1].
I authorize the above agency to release copies of my medical records to the [institution],
MESA. This information will be used to statistical purposes only, and will remain
strictly confidential.

_______________________________________

_____________________

Signature of Patient

Date

MESA MANUAL OF OPERATIONS

E.2.6

Sample Letters for MESA Events

Appendix E, Page

7

MEREL (Medical examiner record release form, if needed)

MESA STUDY MEDICAL EXAMINER RECORD RELEASE FORM

Patient:

[participant name]
[participant street address]
[participant city, state zip]

County:

[county name]

I, [contact/next of kin name], the closest relative of [participant], who is deceased, give
permission for the County Medical Examiner to release medical information to the
[institution], Multi-Ethnic Study of Atherosclerosis (MESA). This information will be
used to statistical purposes only, and will remain strictly confidential.

_______________________________________
Signature of Next of Kin

_____________________
Date

MESA MANUAL OF OPERATIONS

E.2.3

Sample Letters for MESA Events

Appendix E, Page

4

PHYSREL (Physician/clinic record release form)

MESA STUDY PHYSICIAN/CLINIC RECORD RELEASE FORM

Patient:

[participant name]
[participant street address]
[participant city, state zip]

Hospital:

[doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]

Please release to the Multi-Ethnic Study of Atherosclerosis (MESA):
All records of diagnoses and procedures that occurred during the period [time between
clinic visit and follow-up phone call 1].
I authorize the above agency to release copies of my medical records to the [institution],
MESA. This information will be used to statistical purposes only and will remain strictly
confidential.

_______________________________________

_____________________

Signature of Patient

Date

MESA MANUAL OF OPERATIONS

E.2.5

Sample Letters for MESA Events

Appendix E, Page

6

MELET (Cover letter to next of kin to obtain medical
examiner/coroner reports)

[date]

[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing with regard to our telephone interview on [date] regarding [participant].
Your information has been extremely valuable to the Multi-Ethnic Study of
Atherosclerosis (MESA). Thank you.
[participant]’s death was investigated by the County Medical Examiner’s Office. With
your permission, the MESA would like to review those records to confirm the medical
details. The Medical Examiner requires a written consent for release of medical
information. Would you please sign the enclosed consent form for the Medical Examiner
and return it to us in the enclosed stamped envelope?
Please note your consenting to the release of this information is completely voluntary
and, if you choose to not offer us your consent, it will in no way affect any relationship
you may have with this institution. If you have any questions, please feel free to call
NAME at PHONE NUMBER.
Thank you again for your help in this matter.
Sincerely,

NAME
MESA Study Coordinator

NAME
Principal Investigator
Enclosures: Release Form and Return Envelope

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

Appendix E, Page

12

E.2.11 INFLET (Letter to informant/next of kin, known telephone
number)

[date]

[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States, to ask for your help.
Your name is listed on the death certificate of [participant name] who passed away on
[date of death]. In a few days a member of my staff will be calling to explain further
about the project and seek your permission to ask a few medical questions.
The information you provide will be used for statistical purposes only, and will remain
strictly confidential. Of course, your participation is entirely voluntary, and, if you
choose to not speak with us on this matter, it will in no way affect any relationship you
may have with this institution.
Thank you very much in advance for your help in this important study.
Sincerely,

NAME
Principal Investigator

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

Appendix E, Page

13

E.2.12 INFNONUM (Letter to informant/next of kin, unknown telephone
number)

[date]

[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States, to ask for your help.
Your name is listed on the death certificate of [participant name] who passed away on
[date of death]. We would like to call you to explain more about the project and to ask a
few medical questions, but have been unable to find your telephone number.
Could you take a few moments to fill out and mail the enclosed postcard?
The information we will be calling about will be used for statistical purposes only, and
will remain strictly confidential. Of course, your assistance in our research is entirely
voluntary, and, if you choose to not provide your phone number and speak with us on this
matter, it will in no way affect any relationship you may have with this institution
Thank you very much in advance for your help in the important study.
Sincerely,

NAME
Principal Investigator
Enclosure: Return Postcard

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

Appendix E, Page

14

E.2.13 RETNUM (Reply postcard from informant/next of kin with
telephone number)

POSTCARDS SHOULD BE RETURN-ADDRESSED TO LOCAL SURVEILLANCE
CENTER AND STAMPED.

Dear [name of Surveillance Supervisor]:
I will be able to help with you with the Multi-Ethnic Study of Atherosclerosis (MESA).
_____ I do have a telephone number which is __ __ __ - __ __ __ - __ __ __ __ .
The best times to reach me are __ __ __ __ or __ __ __ __ .
An alternative telephone number is __ __ __ - __ __ __ - __ __ __ __ .
The best times to reach me at this number are __ __ __ __ or __ __ __ __.
_____ I do not have a telephone number, but I agree to be interviewed in person.
I will be calling your staff to set up a time and a place for the interview.
Sincerely,

_____________________
[name of informant]

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

Appendix E, Page

15

E.2.14 INFNEIGH (Letter to neighbor of decedent)

[date]

[neighbor name]
[street address]
[city, state zip]
Dear [neighbor]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States, to ask for your help.
As you may know, [participant name] passed away on [date of death]. As part of the
study, we are systematically attempting to contact a next-of-kin or another person who
lived with the decedent in order to obtain some medical information that would help us to
find out about the circumstances surrounding [participant name]’s death. We have not
been able to locate such a person and since you were [participant name]’s neighbor, we
believe that you may be able to help us do so.
Could you take a few moments to fill out and mail the enclosed postcard?
The information we wish to obtain from the next-of-kin or other person who lived with
[participant name] will be used for research purposes only, and will remain strictly
confidential. Of course, your assistance in this matter is entirely voluntary, and, if you
choose to not speak with us on this matter, it will in no way affect any relationship you
may have with this institution
Thank you very much in advance for your help in this important study.
Sincerely,

NAME
Principal Investigator
Enclosure: Return Postcard

MESA MANUAL OF OPERATIONS

Sample Letters for MESA Events

Appendix E, Page

16

E.2.15 RETNEIGH (Reply postcard from neighbor of decedent)

POSTCARDS SHOULD BE RETURN-ADDRESSED TO LOCAL SURVEILLANCE
CENTER AND STAMPED.

Dear [name of Surveillance Supervisor]:
The following individual(s) was (were) living with [participant name] at the time of
his/her death:
Name

Relationship to
deceased

Present address

Present telephone
number

I do not have any information on persons who were living with [participant name] at the
time of his/her death.
Sincerely,

_________________________
[name of neighbor]