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pdfFrom: The Sister Study
To:
Subject: Sister Study Follow-Up
Dear Ms. ,
Thank you for your continued participation in the Sister Study. We want to
keep in touch with you about your health and contact information. You can
help us do that by taking a minute to complete the Health and Contact
Information Updates.
Beginning this year, we are making update forms available online. You can
complete these updates now by clicking here Please complete these
updates even if you have no changes to report. Information you share
will be kept confidential. Your participation in the Sister Study is completely
voluntary and you may choose to skip questions or stop at any time. For
security purposes, after you log in, you will need to answer a few brief
questions to verify your identity. Your responses will be secured during
Internet transmission. If you are having trouble accessing the link, or have
questions, please check here for the frequently asked questions
(FAQs/Help).
Within the next few weeks we will send you the current issue of the Sister
Study Newsletter (PDF). If we haven't heard from you online, we will include
the Health and Contact Information Updates in the packet. We will send you
updates like this every year. Every other year, we will also include a short
questionnaire with more detailed questions about your health and new
questions about your environment.
Please keep in touch. You can always visit our website at
www.sisterstudy.org for more news about the Sister Study. You can also
update your health and contact information by sending an email to
update@sisterstudy.org or by calling the Sister Study helpdesk toll-free at 1877-4SISTER (1-877-474-7837). Thank you again for your ongoing
contribution to this important research.
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, PhD
Principal Investigator
Click here to complete the updates now.
Date
First Name Last Name
Address1
Address2
City, State Zip
Dear Ms. Last Name:
Thank you for your continued participation in the Sister Study. We want to keep in touch with you about your
health and contact information. You can help us do that by taking a minute to complete and mail back the Health
Update Form and the Contact Information Update Form.
Beginning this year, we are making forms available online. You can complete these updates now at
www.sisterstudy.org/200 AnnualUpdate.htm. To access the web-based forms, you will need your Sister
Study ID number, which is printed at the bottom of this letter. Information you share will be kept confidential. Your
participation in the Sister Study is completely voluntary and you may choose to skip questions or stop at any time.
For security purposes, after you log in, you will need to answer a few brief questions to verify your identity. Your
responses will be secured during Internet transmission.
Even if you have no changes to report, please complete the online forms or the enclosed paper forms.
We have included a postage-paid envelope for your convenience - The Sister Study, 1009 Slater Road, Suite 120,
Durham, NC 27703. We will send you forms like this every year. Every other year, we will also include a short
questionnaire with more detailed questions about your health and new questions about your environment.
You can also update your health and contact information by sending an email to update@sisterstudy.org or by
calling the Sister Study helpdesk toll-free at 1-877-4SISTER (1-877-474-7837). When you call or email us, it will
be helpful to give your Sister Study ID number, which is printed at the bottom of this letter.
Please keep in touch. I hope you find the newsletter we’ve included interesting. You can always visit our website
at www.sisterstudy.org for more news about the Sister Study. Thank you again for your ongoing contribution to
this important research.
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, PhD
Principal Investigator
SIS«StudyID»
FORM: 21
VERS: 05
OMB No. 0925-0522
Sister Study Health Update: Year 1
Please return 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 2007.
1. Since August 2007, has a doctor or other health professional told you that you had any of the following
conditions?
Month and year of diagnosis:
NO
YES
N
Y
a. Breast cancer
/ 2 0 0
a1. Ductal (breast) carcinoma in situ (DCIS)
N
Y
/ 2 0 0
a2. Lobular (breast) carcinoma in situ (LCIS)
N
Y
/ 2 0 0
b.
Lung cancer
N
Y
/ 2 0 0
c.
Ovarian cancer
N
Y
2 0 0
d.
Cancer of the colon or rectum
N
Y
2 0 0
e.
Malignant melanoma
N
Y
2 0 0
f.
Skin cancer (not malignant melanoma)
N
Y
2 0 0
g. Any other type of cancer
N
Y
h. Heart attack (myocardial infarction)
N
Y
/ 2 0 0
What kind: ____________________________
/ 2 0 0
Were you a patient in a hospital overnight?
NO
N
YES
i.
Stroke
N
Y
2 0 0
j.
Asthma
N
Y
2 0 0
k. Hypertension
N
Y
2 0 0
l.
N
Y
/ 2 0 0
m. Hip fracture
N
Y
2 0 0
n. Wrist fracture
N
Y
2 0 0
N
Y
/ 2 0 0
Diabetes
o. Any other major illness
Y
What kind: ____________________________
2. Have you had surgery since Aug. 2007?
N
Y
/ 2 0 0
What kind: ____________________________
3. Today’s date:
(month)
/
(day)
/ 2 0 0
(year)
/ 2 0 0
What kind: ____________________________
Thank you for your continued participation in the Sister Study. Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: update@sisterstudy.org
ID#: SIS
*«StudyID»-hlth*
National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services
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 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 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: update@sisterstudy.org
National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services
Date
FirstName LastName
Address 1
Address 2
City, ST ZIP
Dear Ms. LastName:
Thank you for your continued participation in the Sister Study and for completing your Annual
Health and Contact Information Update forms. In order to keep you updated on the study’s
progress, the most recent Sister Study Newsletter is enclosed. It is one of the many ways we
will communicate with you throughout the study so I hope you find it interesting and informative.
In addition, I invite you to visit our beautiful web site at www.sisterstudy.org for more news
about the Sister Study.
We look forward to contacting you again in the spring of 2010 when it is time to complete your
next update. To report any health or contact information changes in the meantime, please call
toll-free at 1-877-4SISTER (1-877-474-7837) or email info@sisterstudy.org.
With your participation in the Sister Study you are making a powerful contribution in helping find
the causes of breast cancer so that future generation don’t have to face this disease. Again,
thank you for your participation in this important research.
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, PhD
Principal Investigator
SISID
Date
First Name Last Name
Address1
Address2
City, State Zip
Dear Ms. Last Name:
We still need your Sister Study Annual Update – we recently sent you a Health Update Form
and Contact Information Update Form. Please take a few minutes to complete and return your
Annual Update today even if you have no changes to report. The success of the study
depends on our ability to track changes in your health and stay in touch over the years.
If you prefer, you can complete these forms online at
www.sisterstudy.org/200 AnnualUpdate.htm. To access the web-based forms, you will need
your Sister Study ID Number which is printed at the bottom of this letter. For security purposes,
after you log in, you will need to answer a few brief questions to verify your identity. Your
responses will be secured during Internet transmission.
You can also complete these questionnaires over the telephone by calling the Sister Study
helpdesk toll-free at 1-877-4SISTER (1-877-474-7837) or by emailing us at
update@sisterstudy.org.
Information you share will be kept confidential. Your participation in the Sister Study is
completely voluntary and you may choose to skip questions or stop at any time. If you have
already returned your forms, please accept our thanks for your continued participation in the
Sister Study.
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, Ph.D.
Principal Investigator
1. Hello, my name is… and I am calling on behalf of the Sister Study. I'd like to speak with
[PARTICPANT NAME]. Is that you?
1 YES
2 NO
3 POSSIBLE WRONG NUMBER
GO TO 6
GO TO 2
GO TO 3
2. May I speak with [PARTICPANT NAME]?
1 R AVAILABLE
2 R NOT AVAILABLE
3 POSSIBLE WRONG #
GO TO 6
DETERMINE CALLBACK TIME, RECORD IN COMMENTS
AND FLAG FRONT OF THIS FORM
GO TO 3
3. Did I reach [PHONE NUMBER]?
1 YES
2 NO
GO TO 4
I'm sorry to have disturbed you. REDIAL THE TELEPHONE NUMBER.
4. IF NECESSARY: Is this the number for [PARTICPANT NAME]?
1 YES, RIGHT NUMBER FOR R.
2 NO, NOT THEIR NUMBER
GO TO 2
GO TO 5
5. IF APPROPRIATE: Could you give me the address or phone number for [PARTICPANT NAME]?
1
YES
2
NO
Thank you for your help. Good-bye. UPDATE NUMBER ON LABEL AND
ATTEMPT CONTACT AT NEW #
Thank you for your help. Good-bye. BE SURE TO RECORD ANYTHING
YOU LEARNED ABOUT HOW TO LOCATE R. CODE AS WRNG.
6. REINTRODUCE SELF IF NECESSARY: I am calling on behalf of the Sister Study. We recently
sent you a packet containing a newsletter and a brief questionnaire about your health. We have not
yet received the questionnaire back so we are calling to ask if you would help by taking a few minutes
to answer these questions with us now over the phone.
1
YES
2 NOT A GOOD TIME NOW
3
ALREADY RETURNED
PROCEED TO HEALTH UPDATE QUESTION 1,
THEN GO TO 7 ON NEXT PAGE OF THIS FORM
DETERMINE CALLBACK TIME, RECORD IN
COMMENTS AND FLAG FRONT OF THIS FORM
Thank you very much. We'll hope to receive your
questionnaire in the next week or so. We may call you in
a couple of weeks if it still hasn't arrived. Good-bye.
CODE AS MAIL.
7. Thank you. We will send you an update like this every year. Every other year, we will also include a
questionnaire with more detailed questions about your health and new questions about your
environment.
We would also like to update your contact information.
REFER TO THE CONTACT UPDATE FORM AND PROMPT:
Have there been any changes to your:
Name
Mailing address
Street address
Any of your phone numbers
Any email address
Also, have there been any changes to the information for the contact people you provided?
PROMPT FOR NAME, RELATIONSHIP, ADDRESS, PHONE NUMBER
FILL IN TODAY’S DATE ON BOTH FORMS AND THE STUDY ID IN THE SPACES
PROVIDED. ENTER THE HEALTH UPDATE “YEAR” ON THE PURPLE FORM.
Thank you for your help. You can update us with your contact information at any time by sending an
email to update@sisterstudy.org or by calling the Sister Study helpdesk toll-free at 1-877-4SISTER
(1-877-474-7837). When you call or email us, it will be helpful to give your Sister Study ID number,
which is (REFER TO ID ON PAGE 1).
You can always visit our website at www.sisterstudy.org for more news about the Sister Study.
Thank you again for contributing to this important research.
CODE AS COMP.
COMMENTS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Biennial Follow-up
Cover Letter
Date
FirstName LastName
Mailing Address 1
Mailing Address 2
City, State Zip
Dear Ms. Last Name:
It is once again time to update your health and contact information. As you may remember, every two to
three years we will be asking detailed questions to collect updated and new information about your
environment and health. Information about changes in your health and exposures will allow us to learn how
environmental and lifestyle factors contribute to developing breast cancer and other conditions. This year, we
ask you to complete updates about your Health and Medical History, Lifestyle and Environment, and Stress
and Coping.
You can help by completing and mailing back the enclosed forms as soon as possible. Information you share
will be kept confidential. Your participation in the Sister Study is completely voluntary and you may choose
to skip questions or stop at any time. :HKDYHLQFOXGHGDSRVWDJHSDLGHQYHORSHIRU\RXUFRQYHQLHQFH
7KH6LVWHU6WXG\ 6ODWHU5RDG6XLWH'XUKDP1&
Enclosed you will also find a Contact Information Update Form displaying information currently in our
records. Even if you have no changes to report, please complete this update by returning the form in the
enclosed postage-paid envelope.
Please keep in touch. I hope you find the newsletter we’ve included interesting. You can always visit our
website at www.sisterstudy.org for more news about the Sister Study. If you have any questions, please
email us at update@sisterstudy.org or call us at our toll-free number 1-877-4SISTER (1-877-474-7837).
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, Ph.D.
Principal Investigator
Enclosures (7)
Form: 37
Vers:
04
ID#: SIS
OMB No. 0925-0522
The Sister Study
Health and Medical History
Version 4
Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Do not write comments on the form.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.
Like this:
Not like this:
2 3
If you must change an answer, please mark a single horizontal line through it and bubble in the
correct answer completely.
Like this:
YES
Not like this:
2
YES
Please write responses in all capital letters and numbers without touching the sides of the boxes.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.
EXAMPLE: June 7, 2004 =
0 6 / 0 7 / 2 0 0 4
(month)
(day)
(year)
Public reporting burden for this collection of information is estimated to average 20 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.
National Institute of Environmental Health Sciences / National Institutes of Health / Department of Health and Human Services
25480
1
25480
2
Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If you
are not comfortable answering a question, just skip it and go to the next one. All information you share
will be kept confidential.
/
Today's Date:
(month)
/
(day)
2
0
(year)
1. In the past 24 months, would you say your health has generally been…
Excellent
Very good
Good
Fair
Poor
2. In the past 24 months, have you...
No
Yes
a. had a routine physical exam?
b. been to a dentist for a routine check-up or cleaning?
c. had a Pap smear?
d. had a breast exam by a doctor or other health professional?
e. had a screening mammogram?
f. had a screening ultrasound of the breast?
g. had a screening MRI of the breast?
h. had a bone density scan or osteoporosis screening?
i. had a screening colonoscopy or sigmoidoscopy exam?
j. had an ultrasound of the uterus?
25480
3
Please use a ballpoint pen for this form
GENERAL HEALTH
3. Do you have any form of general health care coverage, including health insurance, prepaid plans such
as HMOs, or government plans such as Medicare or Medicaid?
No
Yes
GO TO QUESTION 4
3a.
Does your health care insurance cover all
or some of the cost of breast screening
exams such as mammograms, digital
mammography, breast ultrasound, or
breast MRI?
No
Yes
4. Was there a time in the past 12 months when you needed to see a doctor but did not because of the
cost?
No
Yes
5. What is your current weight (in pounds)?
POUNDS
6. What is your current height?
FEET
INCHES
7. In the past 12 months, did you have a flu shot? A flu shot is usually given in the fall and protects
against influenza for the flu season.
No
Yes
GO TO THE NEXT PAGE, QUESTION 8
7a.
In what month and year did
you have a flu shot?
/
MONTH
2
0
YEAR
25480
4
8. In the past 12 months, did you have a flu vaccine sprayed in your nose by a doctor or other health
professional? This vaccine is often called FluMist. A health professional may let you spray it yourself.
This flu vaccine is usually given in the fall and protects against influenza for the flu season.
No
Yes
GO TO QUESTION 9
8a.
In what month and year did
you receive the flu vaccine by
nasal spray?
/
2
0
MONTH
YEAR
No
Yes
GO TO QUESTION 10
9a.
9b.
Did a doctor confirm that this
was the flu?
In what month and year did you
have the flu?
No
Yes
/
MONTH
2
0
YEAR
FAMILY MEDICAL HISTORY
10.
Since August 1, 2006, were any of your sisters diagnosed with breast cancer for the first time?
No
Yes
GO TO THE NEXT PAGE, QUESTION 11
10a.
In all, how many sisters who share at least
one biological parent with you have ever
been diagnosed with breast cancer?
# SISTERS
25480
5
Please use a ballpoint pen for this form
9. In the past 12 months, did you have the flu? The flu is a respiratory illness with fever. Other
symptoms include weakness, fatigue, and muscle aches.
11.
Since August 1, 2006, have any other close blood relatives of yours been diagnosed with breast
cancer?
No
Yes
GO TO QUESTION 12
11a.
What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)
Mother
Father
Brother
Daughter
Son
Grandmother
Grandfather
Other relative related
to you by blood
12.
Since August 1, 2006, have any close blood relatives of yours been diagnosed with ovarian cancer?
No
Yes
13.
GO TO QUESTION 13
12a.
What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)
Sister
Mother
Daughter
Grandmother
Other relative related
to you by blood
Have any close blood relatives of yours ever been diagnosed with asthma?
No
Yes
GO TO THE NEXT PAGE, QUESTION 14
13a.
What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)
Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood
25480
6
PERSONAL MEDICAL HISTORY
We are interested in changes to your health in the few years since you joined the study. Please think
about your medical history since August 1, 2006.
Has a doctor or other health
professional told you that
you had...
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
15. ductal (breast)
carcinoma in situ (DCIS)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
16. lobular (breast)
carcinoma in situ (LCIS)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
17. lung cancer?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
19. cancer of the uterus or
endometrium?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
20. cancer of the colon or
rectum?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
21. malignant melanoma?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
22. skin cancer
(not malignant
melanoma)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
23. leukemia?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
24. Hodgkin’s disease or
Hodgkin’s lymphoma?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
25. non-Hodgkin’s
lymphoma?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
18. ovarian cancer?
/
2
MONTH
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
MONTH
0
2
0
YEAR
25480
7
Please use a ballpoint pen for this form
14. breast cancer? Please
do not include in situ
cancer.
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
Has a doctor or other
health professional told
you that you had...
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
a. MONTH/YEAR DIAGNOSED
26. any other type of cancer
not already listed?
Never diagnosed
Diagnosed before
August 1, 2006
/
Diagnosed August 1,
2006 or later
2
MONTH
0
YEAR
b. Please specify what
type of cancer:
c. If you were diagnosed
with a second other
type of cancer August
1, 2006 or later, what
month and year were
you diagnosed?
/
2
MONTH
0
YEAR
d. Please specify what
type of cancer:
27. a heart attack or
myocardial infarction?
Never diagnosed
Diagnosed before
August 1, 2006
/
Diagnosed August 1,
2006 or later
MONTH
2
0
YEAR
25480
8
Has a doctor or other
health professional ever
told you that you had...
28. hypertension or
high blood
pressure?
NO
No
b.
Do you still
have this
condition?
YES
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
2
MONTH
29. angina?
No
YEAR
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
2
MONTH
30. cardiac arrhythmia
(irregular
heartbeat)?
No
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
2
MONTH
No
0
YEAR
/
31. congestive heart
failure?
0
0
YEAR
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
MONTH
2
0
YEAR
25480
9
Please use a ballpoint pen for this form
/
Has a doctor or other
health professional told
you that you had...
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
32. a stroke (this does not
include TIA or
"mini-stroke")?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
33. a mini-stroke or TIA
(transient ischemic
attack)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
Have you had...
NEVER OR BEFORE
8/1/2006
a.
How many
times has this
happened since
August 1, 2006?
Never
Before August 1,
2006
Occurred August 1,
2006 or later
35. a wrist
fracture?
Never
Before August 1,
2006
Occurred August 1,
2006 or later
36. Have you ever had hip
replacement surgery?
No
2
/
2
a.
If yes, how many hip
replacements have you
ever had?
one hip
both hips
Yes
b.
What was the month
and year that this first
happened since August 1,
2006?
2
MONTH
0
YEAR
/
# TIMES
0
YEAR
/
# TIMES
0
YEAR
MONTH
8/1/2006
OR LATER
YES
/
MONTH
34. a hip
fracture?
NO
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
MONTH
2
0
YEAR
b.
What was the month
and year of your first hip
replacement surgery?
/
MONTH
YEAR
25480
10
NO
37. Has a doctor or other
health professional ever
told you that you had
diabetes?
No
YES
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
MONTH
2
0
YEAR
No
Yes
c. Do you currently take insulin for diabetes?
No
Yes
GO TO QUESTION 38
d. If yes, when did you first use insulin?
/
MONTH
Has a doctor or
other health
professional ever
told you that you
had...
38. allergic
rhinitis,
hay fever, or
seasonal
allergies?
NO
No
YEAR
b.
Have you
experienced
any symptoms
in the past 12
months?
YES
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
2
MONTH
39. asthma?
No
0
YEAR
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
MONTH
2
0
YEAR
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11
Please use a ballpoint pen for this form
b. Do you still have this condition?
Has a doctor or other
health professional told
you that you had...
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
40. chronic bronchitis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
41. emphysema?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
42. chronic obstructive
pulmonary disease
(COPD)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
43. Graves' disease?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
44. other hyperthyroidism
(overactive thyroid)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
45. Hashimoto's thyroiditis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
46. other hypothyroidism
(underactive thyroid)?
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
/
2
MONTH
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
MONTH
0
2
0
YEAR
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12
Has a doctor or other
health professional told
you that you had...
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
48. thyroid nodules?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
49. another thyroid problem?
Please do not include
thyroid cancer.
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
a. MONTH/YEAR DIAGNOSED
/
2
MONTH
0
YEAR
b. Please specify the problem:
50. osteoporosis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
51. osteopenia, or low bone
density?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
52. rheumatoid arthritis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
53. other arthritis (for
example, age or injury
related)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
54. multiple sclerosis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
55. scleroderma or systemic
sclerosis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
56. systemic lupus
erythematosus (SLE)?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
57. discoid lupus?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
58. Crohn’s disease?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
/
2
MONTH
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
MONTH
0
2
0
YEAR
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13
Please use a ballpoint pen for this form
47. an enlarged thyroid or
goiter?
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
Has a doctor or other
health professional told
you that you had...
59. ulcerative colitis?
60. shingles?
61.
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
/
2
0
MONTH
YEAR
/
2
0
MONTH
YEAR
Has a doctor or other health professional ever told you that you had migraine headaches?
No
Yes
GO TO THE NEXT PAGE, QUESTION 62
61a.
Were you diagnosed with migraine
headaches before August 1, 2006?
No
Yes
61b.
Were you [also] diagnosed with
migraines August 1, 2006 or later?
No
Yes
61c.
If you were diagnosed August 1,
2006 or later, what month and year
were you diagnosed?
GO TO 61d
/
MONTH
2
0
YEAR
61d.
Was the diagnosis of migraine made
by a...
(Please mark all that apply.)
Headache specialist
Neurologist
Other physician
Other health professional
61e.
Before a migraine attacks, do you
usually have aura symptoms?
No
Yes
61f.
During the past 12 months, how
often have you had a migraine?
Never
1-2 times
3-5 times
6-11 times
Once per month
2-3 times per month
Once per week
2-4 times per week
5 or more times per week
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14
Has a doctor or other
health professional ever
told you that you had...
NO
62. depression?
No
b.
Do you still
have this
condition?
YES
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
2
MONTH
63. periodontal or gum
disease?
No
YEAR
No
Yes
Yes, first diagnosed before August 1, 2006
Yes, first diagnosed
August 1, 2006 or later
a. What month and year
were you diagnosed?
/
2
MONTH
Has a doctor or other
health professional told
you that you had...
0
NEVER OR BEFORE
8/1/2006
DIAGNOSED
8/1/2006 OR LATER
64. polyps in the colon or
rectum?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
65. polycystic ovaries or
PCOS?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
66. endometriosis?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
67. uterine fibroids or fibroid
tumors?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
68. gallstones or gallbladder
disease?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
0
YEAR
a.
If diagnosed August 1, 2006
or later, what month and
year were you diagnosed?
/
2
MONTH
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
2
MONTH
0
YEAR
/
MONTH
0
2
0
YEAR
25480
15
Please use a ballpoint pen for this form
/
The following are some conditions we have not asked about in the past. Please tell us if you have
ever been diagnosed with any of these conditions and when you were first diagnosed.
Has a doctor or other health professional ever
told you that you had...
NO
No
69. Sjögren’s syndrome?
YES
a.
If yes, what year were
you first diagnosed?
Yes
YEAR
No
70. Parkinson’s disease?
Yes
YEAR
No
71. Alzheimer’s disease?
Yes
YEAR
72. kidney failure requiring dialysis or transplant?
No
Yes
YEAR
No
73. kidney stones?
Yes
YEAR
No
74. other kidney disease?
Yes
YEAR
No
75. cataracts?
Yes
YEAR
No
76. glaucoma?
Yes
YEAR
No
77. macular degeneration?
Yes
YEAR
No
78. doctor-diagnosed hearing loss?
Yes
YEAR
No
78x. gout?
Yes
YEAR
25480
16
79. Since August 1, 2006, has a doctor or other health professional told you that you had any other
major illness?
Never diagnosed
Diagnosed before
August 1, 2006
Diagnosed August 1,
2006 or later
GO TO QUESTION 80
79a. If you were diagnosed
August 1, 2006 or later,
what month and year were
you diagnosed?
MONTH
0
YEAR
FIRST OTHER MAJOR ILLNESS
79c. If you were diagnosed with
a second other major illness
August 1, 2006 or later, what
month and year were you
diagnosed?
79d. Please specify
the problem:
2
/
2
MONTH
0
YEAR
SECOND OTHER MAJOR ILLNESS
80. Since August 1, 2006, have you had any other major injury?
Never had a major
injury
Injured before
August 1, 2006
Injured August 1,
2006 or later
GO TO THE NEXT PAGE, QUESTION 81
80a. If you were injured
August 1, 2006 or later,
what month and year were
you injured?
80b. Please specify what
type of injury:
/
MONTH
0
YEAR
FIRST OTHER MAJOR INJURY
80c. If you were injured with
a second other major injury
August 1, 2006 or later, what
month and year were you
injured?
80d. Please specify what
type of injury:
2
/
MONTH
2
0
YEAR
SECOND OTHER MAJOR INJURY
25480
17
Please use a ballpoint pen for this form
79b. Please specify
the problem:
/
81. Since August 1, 2006, have you experienced any of the following medical symptoms?
Please mark a response for each item below.
No
Yes
No
Yes
a. swelling in your wrist, finger, elbow, or knee joints lasting six or more weeks?
b. joint stiffness in the mornings, lasting at least one hour, and for more than six
weeks (do not include stiffness related or due to an injury or surgery)?
c. daily, persistent, troublesome dry eyes, or a recurrent feeling of sand or gravel in
your eyes, or use of tear substitutes more than 3 times a day for at least 3 months?
d. a daily feeling of dry mouth, or frequent drinking of liquids to aid in swallowing dry
foods, or recurrently or persistently swollen salivary glands for more than 3 months?
e. a tremor or trembling in either of your hands that is worse when you are not using
the hand compared to when you are using it?
f. walking or other movements getting noticeably slower?
g. handwriting getting noticeably smaller?
h. difficulty getting started when walking or making other movements?
i. wheezing or whistling in your chest?
j. shortness of breath when hurrying on level ground, or when walking up a slight hill, or
when climbing a flight of stairs at your usual pace?
82. Have you experienced the following at least once a week in the past year?
a. heartburn (a burning discomfort behind the breast bone in your chest)?
b. acid regurgitation (a bitter or sour tasting fluid coming into your throat or mouth)?
NO
83. Since August 1, 2006, have you
experienced coughing on most days for
three months or more out of a year?
84. Since August 1, 2006, have you brought
up phlegm on most days for three months
or more out of a year (do not count
phlegm from the nose)?
YES
a.
If yes, for how many years
have you had this symptom?
No
Yes
1 year
2 or more years
No
Yes
1 year
2 or more years
25480
18
For the next few questions, please think about your breast health over your lifetime.
85.
Have you ever been told you had abnormal findings on your mammogram, breast ultrasound, or breast
MRI?
No
Yes
GO TO THE NEXT PAGE, QUESTION 86
85a. On how many occasions did this
happen?
85c. What was the month and year of
your most recent test with
abnormal findings?
AGE
/
MONTH
YEAR
85d. Which breast showed abnormal
findings at the most recent test?
Left breast
Right breast
Both breasts
85e. After completing the work-up
for this abnormal test, what was
the doctors’ recommendation?
Did they tell you to...
Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a breast biopsy, surgery,
or other treatment
Don't know
85f. Were you told this test showed
any of the following?
(Please mark all that apply.)
Breast cysts
Fibrocystic breasts
Breast calcifications
Dense breasts
Uneven or one-sided densities
Fibroadenoma
Other
Don't know
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19
Please use a ballpoint pen for this form
85b. How old were you when you
had your first abnormal
mammogram, breast ultrasound,
or breast MRI?
# OCCASIONS
86.
Have you ever had a breast cyst or cysts drained (aspirated) or removed?
No
Yes
GO TO THE NEXT PAGE, QUESTION 87
86a. On how many occasions have
you had this?
86b. How old were you the first
time you had this?
86c. What was the month and year of
your most recent procedure?
# OCCASIONS
AGE
/
MONTH
YEAR
86d. On which breast was the most
recent cyst aspiration or
removal performed?
Left breast
Right breast
Both breasts
86e. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...
Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a breast biopsy, surgery,
or other treatment
Don't know
25480
20
87.
Have you ever had a needle biopsy to diagnose or rule out a breast condition?
No
Yes
GO TO THE NEXT PAGE, QUESTION 88
87a. On how many occasions have
you had this?
87c. What was the month and year of
your most recent procedure?
AGE
/
MONTH
YEAR
87d. On which breast was the most
recent needle biopsy
performed?
Left breast
Right breast
Both breasts
87e. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...
Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a different type of breast
biopsy, surgery, or other
treatment
Don't know
25480
21
Please use a ballpoint pen for this form
87b. How old were you the first
time you had this?
# OCCASIONS
88.
Have you ever had a surgical biopsy or a biopsy other than a needle biopsy to diagnose or rule out a
breast condition?
No
Yes
GO TO THE NEXT PAGE, QUESTION 89
88a. On how many occasions have
you had this?
88b. How old were you the first
time you had this?
88c. What was the month and year of
your most recent procedure?
# OCCASIONS
AGE
/
MONTH
YEAR
88d. On which breast was the most
recent biopsy performed?
Left breast
Right breast
Both breasts
88e. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...
Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a different type of breast
biopsy, surgery, or other
treatment
Don't know
25480
22
89.
Have you ever had a breast lump or lumps removed (lumpectomy)?
No
Yes
GO TO THE NEXT PAGE, QUESTION 90
89a. On how many occasions have
you had this?
AGE
/
89c. What was the month and year of
your most recent procedure?
MONTH
YEAR
89d. On which breast was the most
recent lumpectomy performed?
Left breast
Right breast
Both breasts
89e. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...
Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a different type of biopsy,
surgery, or other treatment
Don't know
25480
23
Please use a ballpoint pen for this form
89b. How old were you the first
time you had this?
# OCCASIONS
90.
Have you ever had a mastectomy of your left breast?
No
Yes
GO TO QUESTION 91
90a. Why was this done?
To treat breast cancer
To prevent breast cancer
Both
90b. When was this done?
Before August 1, 2006
August 1, 2006 or later
90c. If you had this
procedure August 1,
2006 or later, what was
the month and year?
91.
/
2
MONTH
GO TO 91
0
YEAR
Have you ever had a mastectomy of your right breast?
No
Yes
GO TO THE NEXT PAGE, QUESTION 92
91a. Why was this done?
91b. When was this done?
91c. If you had this
procedure August 1,
2006 or later, what was
the month and year?
To treat breast cancer
To prevent breast cancer
Both
Before August 1, 2006
August 1, 2006 or later
/
MONTH
2
GO TO 92
0
YEAR
25480
24
Were you ever told you had any of the following after a cyst aspiration, cyst removal, biopsy,
lumpectomy, or mastectomy?
NO
92.
93.
fibrocystic or benign changes (within
normal range)
No
fibroadenoma
No
YES
a.
IF YES, how old were you when
you were first told you had this?
Yes
AGE
Yes
Please use a ballpoint pen for this form
AGE
94.
No
proliferative changes
Yes
AGE
95.
No
ductal hyperplasia
Yes
AGE
96.
No
lobular hyperplasia
Yes
AGE
97.
No
ductal carcinoma in situ (DCIS)
Yes
AGE
98.
No
lobular carcinoma in situ (LCIS)
Yes
AGE
99.
No
breast cancer
Yes
AGE
100.
No
other changes
Yes
AGE
101.
Did you keep a copy of the pathology report(s) from the cyst aspiration, cyst removal, biopsy,
lumpectomy, or mastectomy that you are willing to share with us?
No
Yes
PLEASE INCLUDE A COPY WITH YOUR COMPLETED QUESTIONNAIRE.
Not applicable
25480
25
102.
103.
breast reduction
surgery of your left
breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
breast reduction
surgery of your right
breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
Have you ever had...
104.
105.
106.
107.
8/1/2006
OR LATER
NEVER OR BEFORE
8/1/2006
Have you ever had...
NEVER OR BEFORE
8/1/2006
a.
If you had this procedure August
1, 2006 or later, what was the
month and year?
8/1/2006
OR LATER
breast
reconstruction
surgery of your
left breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
breast
reconstruction
surgery of your
right breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
breast
enlargement
surgery of your
left breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
breast
enlargement
surgery of your
right breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
/
2
MONTH
YEAR
/
2
MONTH
a.
If you had this procedure
August 1, 2006 or later, what
was the month and year?
/
2
MONTH
MONTH
MONTH
MONTH
/
2
/
2
/
2
0
0
YEAR
b.
Did you have
a silicone gel
implant?
0
No
YEAR
Yes
0
No
YEAR
Yes
0
No
YEAR
Yes
0
No
YEAR
Yes
25480
26
Have you
ever had...
108.
a breast implant
surgically removed
from your left
breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
a breast implant
surgically removed
from your right
breast?
Never
Yes, before
August 1, 2006
Yes, August 1,
2006 or later
/
2
MONTH
/
MONTH
2
b.
Was this a
silicone gel
implant?
0
No
YEAR
Yes
0
No
YEAR
Yes
25480
27
Please use a ballpoint pen for this form
109.
8/1/2006
OR LATER
NEVER OR BEFORE
8/1/2006
a.
If you had this procedure
August 1, 2006 or later,
what was the month and
year?
110.
Are you currently pregnant or breastfeeding?
No
GO TO NEXT QUESTION, 110a
Yes
GO TO PAGE 30, QUESTION 111
110a. Have you had a menstrual period in the past 12 months?
No
ANSWER BOX A BELOW
Yes
ANSWER BOX B ON THE NEXT PAGE
BOX A
FOR WOMEN WHO HAVE NOT HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS. ALL OTHERS GO
TO QUESTION 110d.
110b. Why did your periods stop?
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement therapy
before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 151 and 152).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that suppresses ovarian function.
My periods stopped because I am taking the kind of birth control pills that
eliminate periods.
My periods stopped for some other reason, please describe:
110c. 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
GO TO PAGE 30, QUESTION 111
25480
28
BOX B
FOR WOMEN WHO HAVE HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS.
110d. When was your last menstrual period?
MONTH
/
DAY
2
0
YEAR
110e. What statement best describes you?
My periods have not stopped and I am not taking hormones.
My periods have not stopped but I am taking hormones.
My periods stopped temporarily, but restarted when I began
hormone replacement therapy.
GO TO PAGE 30,
QUESTION 111
OR
My periods stopped sometime in the last 12 months.
GO TO QUESTION 110f
110f. Why did your periods stop?
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement
therapy before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 151 and 152).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that suppresses ovarian function.
My periods stopped because I am taking the kind of birth control pills that
eliminate periods.
My periods stopped for some other reason, please describe:
25480
29
Please use a ballpoint pen for this form
/
REPRODUCTIVE HISTORY AND HORMONES
111.
Have you been pregnant since August 1, 2006?
No
Yes
GO TO PAGE 32, QUESTION 118
111a. Are you currently pregnant?
111b. How many times have you been
pregnant since August 1, 2006
(including your current
pregnancy, if applicable)?
No
Yes
# TIMES
25480
30
THIS SECTION IS FOR WOMEN WHO HAVE BEEN PREGNANT SINCE AUGUST 1, 2006. ALL
OTHERS GO TO THE NEXT PAGE, QUESTION 118.
112.
How did this
pregnancy end?
FIRST PREGNANCY
SECOND PREGNANCY
(since August 1, 2006)
(since August 1, 2006)
Still pregnant now
Single live birth
Twins, live births
Other multiple live births
Still pregnant now
Single live birth
Twins, live births
Other multiple live births
Stillbirth(s)
114.
How many weeks
did this pregnancy
last (or has it
lasted, if now
pregnant)?
Stillbirth(s)
# BABIES
Miscarriage
Miscarriage
Induced abortion
Induced abortion
Molar or ectopic pregnancy
Molar or ectopic pregnancy
less than 8 weeks
8 to 12 weeks
13 to 16 weeks
17 to 24 weeks
less than 8 weeks
8 to 12 weeks
13 to 16 weeks
17 to 24 weeks
25 to 36 weeks
25 to 36 weeks
37 to 41 weeks
37 to 41 weeks
42 weeks or more
42 weeks or more
What month and
year did this
pregnancy end?
/
2
/
0
MONTH
116.
How long did you
breastfeed (or
have you been
breastfeeding)?
Single male
Single female
Multiple
Don't know
Still pregnant now
# MALES # FEMALES
}
less than one month
1-3 months
4-6 months
7-12 months
13-24 months
GO TO 117
more than 24 months
did not breastfeed/
not applicable
117.
Are you still
breastfeeding?
YEAR
OR
Still pregnant now
What was the sex
of the baby or
babies?
0
MONTH
YEAR
OR
115.
2
GO TO NEXT
PREGNANCY OR
QUESTION 118
Single male
Single female
Multiple
Don't know
# MALES # FEMALES
}
less than one month
1-3 months
4-6 months
7-12 months
13-24 months
GO TO 117
more than 24 months
did not breastfeed/
not applicable
no
no
yes
yes
IF YOU HAVE HAD MORE THAN 2 PREGNANCIES SINCE AUGUST 1, 2006,
PLEASE ANSWER THE SAME QUESTIONS FOR EACH PREGNANCY AND
RECORD YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
31
GO TO NEXT
PREGNANCY OR
QUESTION 118
25480
Please use a ballpoint pen for this form
113.
# BABIES
Since August 1, 2006,
have you used...
118.
birth control pills?
NO
No
YES
a.
If yes, how many months in
all have you used this since
August 1, 2006?
b.
Are you currently
using this?
No
Yes
Yes
# MONTHS
119.
birth control patches?
No
No
Yes
Yes
# MONTHS
120.
121.
a hormonal IUD
(intrauterine device)?
No
a Norplant implant?
No
No
Yes
Yes
# MONTHS
No
Yes
Yes
# MONTHS
122.
a Nuva Ring?
No
No
Yes
Yes
# MONTHS
123.
Depo Provera?
No
No
Yes
Yes
# MONTHS
124.
any other hormonal
birth control?
No
No
Yes
Yes
# MONTHS
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32
125.
Since August 1, 2006, have you taken any fertility medications?
No
GO TO THE NEXT PAGE, QUESTION 135
Yes
Since August 1, 2006, have you taken...
126.
No
Clomiphene, Clomid, Serophene?
YES
Please use a ballpoint pen for this form
NO
a.
If yes, how many months or
cycles in all have you used this
since August 1, 2006?
Yes
# MONTHS/CYCLES
127.
128.
129.
130.
131.
132.
133.
134.
Follicle-stimulating hormones
(FSH) - Follistim, Puregon,
Gonal-F?
No
Urofollitropin, Metrodin,
Fertinex, Bravelle?
No
Human menopausal
gonadotropin (hMG) - menotropin,
Pergonal, Humegon, Repronex?
No
Human chorionic gonadotropin
(hCG) - Pregnyl, Novarel,
Profasi, A.P.L.?
No
Gonadotropin-releasing hormone (GnRH)
- gonadorelin, Factrel, Lutrepulse,
Synarel, nafarelin acetate; and related
drugs such as Lupron, leuprolide?
No
Gonadotropin inhibitors Danocrine, Danazol, Antagon,
ganirelix acetate?
No
Prolactin reducers Bromocriptine, Parlodel?
No
Other:
No
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
Yes
# MONTHS/CYCLES
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33
The next questions are about female hormone products often used for hormone replacement
therapy (HRT).
Since August 1, 2006, have you
used...
135.
136.
137.
138.
139.
140.
NO
a combined pill containing both
estrogen and progesterone (such
as Prempro)?
No
an estrogen-only pill (such as
Premarin) with no additional
progesterone in any form?
No
an estrogen pill (such as Premarin)
and a separate progesterone pill
(such as Provera) or progesterone
shot?
No
an estrogen-only patch with no
additional progesterone in any form?
No
a patch containing both estrogen and
progesterone (such as Combipatch)?
No
an estrogen-only patch and a separate
progesterone pill or progesterone shot?
No
YES
a.
If yes, how many
months in all have
you used this since
August 1, 2006?
Yes
# MONTHS
Yes
# MONTHS
Yes
# MONTHS
b.
Do you currently
use this female
hormone
product(s)?
No
Yes
No
Yes
No
Yes
No
Yes
Yes
# MONTHS
No
Yes
Yes
# MONTHS
Yes
# MONTHS
No
Yes
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34
Since August 1, 2006, have you
used...
141.
vaginal estrogen creams,
rings, or suppositories?
NO
YES
No
Yes
a.
If yes, how many months in all have
you used this since August 1, 2006?
a.
# MONTHS
b. Do you currently use this female
hormone product(s)?
c. Does this product also contain
progesterone?
No
Yes
Don't know
d. Did you also take progesterone in
another form (e.g., patch, pill)
during the time you were using
vaginal estrogen creams, rings, or
suppositories?
No
Yes
142.
any other estrogen
products, including
“natural” estrogens?
No
Yes
a.
# MONTHS
b. Do you currently use this female
hormone product(s)?
No
Yes
c. Which of the following products
have you used since August 1, 2006?
(Please mark all that apply.)
Capsules
Gel or cream applied to the skin
Injection
Liquid
Troche or lozenge (dissolved
under the tongue)
Other
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35
Please use a ballpoint pen for this form
No
Yes
Since August 1, 2006, have
you used...
143.
NO
YES
No
tamoxifen or Nolvadex?
a.
If yes, how many months in
all have you used this since
August 1, 2006?
b.
Do you
currently
use this?
No
Yes
Yes
# MONTHS
144.
No
raloxifene or Evista?
No
Yes
Yes
# MONTHS
145.
No
Herceptin?
No
Yes
Yes
# MONTHS
146.
147.
aromatase inhibitors
such as Arimidex,
Aromasin, or Femara?
No
testosterone supplements?
No
No
Yes
Yes
# MONTHS
No
Yes
Yes
# MONTHS
SURGERIES
Have you ever had...
148.
149.
150.
NEVER OR BEFORE
8/1/2006
HAD PROCEDURE
8/1/2006 OR LATER
gallbladder
surgery?
Never had procedure
Had procedure before
August 1, 2006
Had procedure
August 1, 2006
or later
angioplasty?
Never had procedure
Had procedure before
August 1, 2006
Had procedure
August 1, 2006
or later
Never had procedure
Had procedure before
August 1, 2006
Had procedure
August 1, 2006
or later
coronary
artery bypass
graft surgery?
a.
If you had this procedure
August 1, 2006 or later, what
was the month and year?
/
2
MONTH
YEAR
/
2
MONTH
0
YEAR
/
MONTH
0
2
0
YEAR
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36
Have you ever had...
151.
a hysterectomy
(surgical
removal of the
uterus)?
NEVER OR BEFORE
8/1/2006
HAD PROCEDURE
8/1/2006 OR LATER
Never had procedure
Had procedure
August 1, 2006
or later
Had procedure before
August 1, 2006
a.
If you had this procedure
August 1, 2006 or later, what
was the month and year?
a. MONTH/YEAR HAD PROCEDURE
/
2
MONTH
0
YEAR
No
Yes
GO TO QUESTION 152
c. Did you have...
both ovaries completely removed
one ovary and part of the
other ovary removed
one ovary removed
part of one or part of both
ovaries removed
d. Did you have all or part of
either ovary left after this
surgery?
No
Yes
152.
a separate
surgery to
remove part or
all of one or
both ovaries
(but not your
uterus)?
Never had procedure
Had procedure
August 1, 2006
or later
Had procedure before
August 1, 2006
a. MONTH/YEAR HAD PROCEDURE
/
2
MONTH
0
YEAR
b. Did you have...
both ovaries completely removed
one ovary and part of the
other ovary removed
one ovary removed
part of one or part of both
ovaries removed
c. Did you have all or part of
either ovary left after this
surgery?
No
Yes
25480
37
Please use a ballpoint pen for this form
b. Did you have all or part of
either of your ovaries
removed at the same time
you had the hysterectomy?
SYMPTOMS OF MENOPAUSE
No
153.
Have you had hot flashes at any time since August 1, 2006?
154.
Have you had night sweats at any time since August 1, 2006?
155.
Have you had any other symptoms of menopause since August 1, 2006,
such as poor sleeping, irritability or depression?
Yes
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38
MEDICATIONS
Since August 1, 2006, have you used any prescription
medicines to treat or to prevent...
NO
YES
a.
If yes, are you
currently using this?
hypertension (high blood pressure)?
No
Yes
No
Yes
157.
high cholesterol?
No
Yes
No
Yes
158.
cardiac arrhythmia (irregular heartbeat)?
No
Yes
No
Yes
159.
diabetes?
No
Yes
No
Yes
160.
thyroid disease?
No
Yes
No
Yes
161.
osteoporosis (bone loss, or bone thinning)?
Do not count calcium or vitamin D.
No
Yes
No
Yes
162.
arthritis?
No
Yes
No
Yes
163.
migraines?
No
Yes
No
Yes
164.
depression?
No
Yes
No
Yes
165.
asthma?
No
Yes
No
Yes
166.
Parkinson’s disease?
No
Yes
No
Yes
167.
anxiety?
No
Yes
No
Yes
168.
Please use a ballpoint pen for this form
156.
Have you had allergy shots since August 1, 2006?
No
Yes
GO TO THE NEXT PAGE, QUESTION 169
168a. Are you still getting these allergy
shots?
No
Yes
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39
Since August 1, 2006, have you
regularly (at least once a week for at
least three months in a row) taken...
169.
170.
171.
172.
173.
acetaminophen (Tylenol)?
“baby aspirin” or low-dose
aspirin (100mg/tablet or less)?
aspirin or other aspirincontaining products
(325 mg/tablet or more)?
ibuprofen (such as Advil,
Motrin, Nuprin, etc.)?
Celebrex, Vioxx, Bextra, or
other COX-2 inhibitors?
NO
YES
No
No
No
No
No
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Yes
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
40
174.
175.
Aleve, Naprosyn, Relafen,
Ketoprofen, Anaprox, or other
non-steroidal anti-inflammatories?
antibiotics?
No
No
a.
If yes, for about how long have you used this
regularly (at least once a week for at least
three months in a row) since August 1, 2006?
25480
40
b.
On average, how many days per
week have you taken this?
c.
On days when you take it, how
many times do you take it?
d.
Are you currently using this?
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
41
time per day
times per day
times per day
times per day
or more times per day
No
Yes
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
No
Yes
Please use a ballpoint pen for this form
1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
25480
41
These last questions are about prescription and non-prescription medications that you currently take
regularly. This includes all pills, patches, shots, inhaled medicines, vitamins, and herbal
supplements. Please include inhalers, even if you use them occasionally and include all medicines
prescribed in once a month or once a year doses such as some medicines to prevent osteoporosis.
Do not include:
· Medicines used only occasionally, such as a pain reliever once in a while for a headache
· Aspirin or other pain medications already reported in previous questions
176.
Do you currently take any prescription or non-prescription medications regularly or seasonally?
Please include inhalers that you currently use as needed.
No
GO TO END, PAGE 47
Yes
TOTAL #
a.
What is/are the name(s) of the prescription or non-prescription medication(s) that
you currently take regularly?
b.
For how long have you
used this regularly?
1.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
2.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
3.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
4.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
5.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
25480
42
d.
On days when you take
it, how many times do
you take it?
Please use a ballpoint pen for this form
c.
How often do you take it?
e.
In what form did you take this? (Mark
all that apply.)
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
25480
43
a.
What is/are the name(s) of the prescription or non-prescription medication(s) that you
currently take regularly? (If you need more space, answer the same questions for each
medication and record it on a separate sheet.)
b.
For how long have you
used this regularly?
6.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
7.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
8.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
9.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
10.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
11.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
12.
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
25480
44
c.
How often do you take it?
d.
On days when you take
it, how many times do
you take it?
e.
In what form did you take this? (Mark
all that apply.)
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
1
2
3
4
5
time per day
times per day
times per day
times per day
or more times per day
pill
inhaler
cream
liquid
patch
spray
shot
other
Please use a ballpoint pen for this form
Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week
25480
45
25480
46
Please check to see that all questions are answered.
Thank you for completing this questionnaire and for your
continued participation in the Sister Study.
Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: update@sisterstudy.org
25480
47
25480
48
Form: 36
Vers:
04
ID#: SIS
OMB No. 0925-0522
The Sister Study
LifestyleDQG(QYLURQPHQW
Version 4
Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Do not write comments on the form.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.
Like this:
Not like this:
2 3
If you must change an answer, please mark a single horizontal line through it and bubble in the
correct answer completely.
Like this:
YES
Not like this:
2
YES
Please write responses in all capital letters and numbers without touching the sides of the boxes.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.
EXAMPLE: June 7, 2004 =
0 6 / 0 7 / 2 0 0 4
(month)
(day)
(year)
Public reporting burden for this collection of information is estimated to average 20 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.
National Institute of Environmental Health Sciences / National Institutes of Health / Department of Health and Human Services
21681
1
Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If you
are not comfortable answering a question, just skip it and go on to the next one. All information you
share will be kept confidential.
/
Today's Date:
(month)
/
(day)
2
0
(year)
1. Which of the following best describes your current marital status?
Never married
Widowed
Divorced
GO TO QUESTION 2
Separated
Married, civil
union or living
with someone as
though married
1a.
How many years have you been married or
living as though married with that
spouse/partner?
OR
Less than 1 year
# YEARS
1b.
Is your spouse/partner a
man or a woman?
Man
Woman
2. Thinking about last year, which of the following best describes your total income from all
household members before taxes? Please include income from all sources such as
annuities, social security, stocks, alimony and child support earned in the past year.
Less than $20,000
$20,000 to $49,999
$50,000 to $99,999
$100,000 to $200,000
More than $200,000
21681
2
3. Last year, how many people, including yourself, were supported by that income?
1
2
3-4
5-6
7-8
More than 8
4. Did you smoke at least 10 cigarettes since August 1, 2006?
GO TO QUESTION 5
4a.
Yes
When did you first start
smoking?
Before 2006
2006
2007
2008
2009
2010
4b.
When did you last smoke
cigarettes?
I
I
I
I
I
I
am a current smoker
last smoked in 2010
last smoked in 2009
last smoked in 2008
last smoked in 2007
last smoked in 2006
4c.
During the years you
smoked since 2006, how
many days per week
do/did you smoke?
Less than one day per week
1-3 days per week
4-6 days per week
every day
4d.
During the years you
smoked since 2006, how
many cigarettes do/did you
usually smoke per day on
the days that you smoked?
# CIGARETTES
5. Since August 1, 2006, how many regular smokers have you lived with (not counting yourself, if
you smoke)?
None
1
2
3-4
5 or more
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3
Please use a ballpoint pen for this form
No
6. About how many hours or minutes per day are you exposed to other people’s tobacco smoke
(include all locations—home, work, and all other places you spend time where others might
smoke)?
None
Less than 30 minutes
30-59 minutes
1-2 hours
3-4 hours
5-6 hours
7-8 hours
More than 8 hours
a.
IF YES, about how
often did you drink
these beverages?
Since August 1, 2006...
7. ...have you drunk
beer or other
malt beverages?
8. ...have you drunk
white wine or
white wine
coolers?
9. ...have you drunk
red wine or red
wine coolers?
10. ...have you
drunk liquor?
NO
no
no
no
no
YES
b.
On average, how
many drinks did
you have on the
days that you
drank?
c.
How many years
in all have you
done this since
August 1, 2006?
yes
a few times per year
once per month
2-3 times per month
once per week
2 times per week
3-4 times per week
5-6 times per week
every day
1
2
3
4
5
6
7 or more
less than 1 year
1 year
2 years
3 years
4 years
5 years
yes
a few times per year
once per month
2-3 times per month
once per week
2 times per week
3-4 times per week
5-6 times per week
every day
1
2
3
4
5
6
7 or more
less than 1 year
1 year
2 years
3 years
4 years
5 years
yes
a few times per year
once per month
2-3 times per month
once per week
2 times per week
3-4 times per week
5-6 times per week
every day
1
2
3
4
5
6
7 or more
less than 1 year
1 year
2 years
3 years
4 years
5 years
yes
a few times per year
once per month
2-3 times per month
once per week
2 times per week
3-4 times per week
5-6 times per week
every 4day
1
2
3
4
5
6
7 or more
less than 1 year
1 year
2 years
3 years
4 years
5 years
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4
11. Since August 1, 2006, did you ever drink four or more alcoholic beverages in a row, in one sitting?
No
GO TO QUESTION 12
11a.
Yes
once or twice
once a year
2-3 times a year
4-6 times a year
7-11 times a year
once a month
How many times has
this happened since
August 1, 2006?
once a week
more than once a week
12. Since August 1, 2006, has a doctor or other health professional told you that your drinking
was hurting your health?
No
Yes
We are interested in finding out about the kinds of physical activities that people do as part of their
everyday lives. The questions will ask you about the time you spent being physically active in the
past 7 days. Please answer each question even if you do not consider yourself to be an active
person. Please think about the activities you do at work, as part of your house and yard work, to get
from place to place, and in your spare time for recreation, exercise or sport.
a.
How much time did you usually
spend doing these physical
activities on one of those days?
During the past 7 days, on how many days did you...
13. ...do vigorous physical activities? These take hard
physical effort and make you breathe much harder
than normal, for example running or swimming at
a fast pace. Think only about activities that you
did for at least 10 minutes at a time.
AND
# DAYS
OR
No vigorous
physical activity
14. ...do moderate physical activities? These take
moderate physical effort and make you breathe
somewhat harder than normal, for example
dancing or doing yard work. Think only about
those physical activities that you did for at least
10 minutes at a time. Do not include walking.
HOURS
PER DAY
MINUTES
PER DAY
(up to 59)
Not sure
AND
# DAYS
OR
No moderate
physical activity
15. ...walk for at least 10 minutes at a time? This
includes walking at work and at home, walking to
travel from place to place, and any other walking
you might do solely for recreation, sport, exercise
or leisure.
HOURS
PER DAY
MINUTES
PER DAY
(up to 59)
Not sure
AND
# DAYS
OR
No walking for at
least 10 mins
HOURS
PER DAY
MINUTES
PER DAY
(up to 59)
Not sure
21681
5
Please use a ballpoint pen for this form
more than once a month
but less than once a week
During the past 7 days, how much time did you...
16. ...usually spend sitting on a weekday? This includes sitting while at
work, at home, while doing course work and during leisure time. This
may include time spent sitting at a desk, visiting friends, reading or
sitting or lying down to watch television.
AND
HOURS
PER DAY
Not sure
MINUTES
PER DAY
(up to 59)
AND
17. ...usually spend standing on a weekday? This includes standing
while at work, at home, and during leisure time.
HOURS
PER DAY
Not sure
MINUTES
PER DAY
(up to 59)
18. How similar was your level of activity this past week to your usual level of activity?
less than usual
about the same
more than usual
19. Since August 1, 2006, have you done any of the following hobbies at least 5 hours per
week for at least 6 weeks? (Mark all that apply.)
oil painting or other artistic painting
developing photographs chemically
woodworking
refinishing furniture
ceramics or pottery making
glass blowing
etching
hobbies that involve soldering such as stained glass or jewelry making
hobbies that involve welding
leather crafting
print making or silk screening
auto or engine repair
gardening
I have not done any of these hobbies
21681
6
20. Since August 1, 2006, have you used hair dye to color your hair?
No
GO TO QUESTION 21
In what years did you
do this? (Mark all that
apply.)
2006
2007
2008
2009
2010
20b.
What color did you
usually use?
Black
Light brown
Dark brown
Light blonde
Dark blonde
Light red
Dark red
Other
20c.
What type of hair dye do you use most often?
Temporary dyes (wash out with a few shampoos)
Semi-permanent dyes (colors are pre-mixed or require
mixing but no other chemicals are added; color fades out
in about 4-8 weeks)
Demi-permanent dyes (other chemicals are mixed with the
color; has strong smell; color fades out)
Permanent dyes (other chemicals are mixed with the color;
has strong smell; color grows out over time, sometimes
leaving your “roots” showing)
Yes
21. Since August 1, 2006, about how often have you used chemical insect repellents on your skin,
hair, or clothing in the summer? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
Every day
22. Since August 1, 2006, about how often have you used chemical insect repellents on your skin,
hair, or clothing the rest of the year? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
21681
Every day
7
Please use a ballpoint pen for this form
20a.
23. Since August 1, 2006, about how often have you used an over-the-counter or prescription lice
control product on yourself, or applied it to someone else’s skin, hair, or clothing?
Never
Once
Twice
Three times
Four or more times
24. Since August 1, 2006, about how many hours per day do you usually spend outdoors in daylight on
weekend or vacation days in the summer?
Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day
25. Since August 1, 2006, about how many hours per day do you usually spend outdoors in daylight on
other days in the summer?
Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day
26. Since August 1, 2006, about how many hours per day do you usually spend outdoors in daylight on
weekend or vacation days the rest of the year?
Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day
27. Since August 1, 2006, about how many hours per day do you usually spend outdoors in daylight on
other days the rest of the year?
Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day
21681
8
28. Since August 1, 2006, when you spent time outdoors, about how often did you use sunscreen or
wear protective clothing such as hats or long sleeves?
Never
Rarely
Sometimes
Usually
Always
29. Have you moved since August 1, 2006?
Yes
GO TO QUESTION 30
29a.
29b.
What month and year did you
move into your current residence?
2
MONTH
Please use a ballpoint pen for this form
No
0
YEAR
Please write down your current address.
STREET #
STREET NAME
APT #
STATE
29c.
CITY OR TOWN
ZIP CODE
COUNTY
Please write down the name of the nearest cross street (the
street that intersects with the street where you live):
NAME OF NEAREST CROSS STREET
30. How many lanes of traffic in total does the street where you live have?
# LANES
31. Which best describes the traffic condition during rush hour on the road where you live?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit
9
21681
32. How much time per day do you spend traveling by bicycle, motorcycle, car, van, truck, or bus
on most days?
Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours
33. What is the traffic condition that best describes your travel time (by bicycle, motorcycle, car,
van, truck, or bus) on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit
Not applicable, I travel by train or subway
Not applicable, I walk to work
34. Since August 1, 2006, about how often has your residence been treated with insecticides or
pesticides to control insects, rodents, or other pests, either inside or around the foundation?
Never
GO TO THE NEXT PAGE, QUESTION 35
Less than once
a year
Once a year
34a.
For what kinds of pests
were pest control
chemicals used at your
residence?
(Mark all that apply.)
Ants
Cockroaches
Bees or wasps
Flies
Spiders
Mosquitoes
Fleas or ticks, not on pets
Termites
Any other pest such as
moths, silverfish,
caterpillars, mice, rats,
gophers, or moles
34b.
When pest control
chemicals were applied
since August 1, 2006,
about how often did you
personally apply them?
All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily
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10
35. Since August 1, 2006, about how often was the garden or yard around this residence treated with
weed killers or insecticides, including those labeled organic such as pyrethrum or rotenone?
Never
Not applicable
GO TO QUESTION 36
Less than once
a year
35a.
All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable
36. Since August 1, 2006, about how often have you used household cleaning solutions other than dish
washing and laundry detergents?
Never
Less than once a year
Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily
37. Since August 1, 2006, have you regularly used air fresheners in your home? Please include air
fresheners that plug in, hang, sit on a shelf, or stick on the wall, as well as sprays that are used
at least three times a week.
No
Yes
GO TO THE NEXT PAGE, QUESTION 38
37a.
What types of air
fresheners do you use at
home? (Mark all that
apply.)
Aerosol sprays
Solid table top
Stick-on (disc shaped)
Plug-in
Candle style
Other
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11
Please use a ballpoint pen for this form
Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily
When weed killers or
insecticides were used
in the garden or yard
since August 1, 2006,
about how often did you
personally apply them?
38. Since August 1, 2006, have you regularly used air fresheners in your car? Please include the
hanging types, as well as those that plug in, and sprays that are used at least three times a week.
No
Yes
GO TO QUESTION 39
38a.
What types of air
fresheners do you use
in your car? (Mark all
that apply.)
Aerosol sprays
Hanging type - paper
Hanging type - gel
Hanging type - other
Canister type
Attached to car air vent - oil filled
Attached to car air vent - gel filled
Attached to car air vent - stick filled
39. Do you currently have any household pets?
No
Yes
GO TO QUESTION 40
How many of each of the following do you have?
None
39a.
39b.
39c.
39d.
1
2
3-4
5 or more
dogs
birds
cats
other furry animals
40. Since August 1, 2006 have you had a full-time or part-time job other than homemaking that you
held for at least 12 months (at least 9 months if it was a teaching job)?
No
40a.
Which of the following
best describes your
current situation?
Homemaker
Student
Unemployed
Retired
On medical leave
Disabled
GO TO THE END
Yes
GO TO THE NEXT PAGE, QUESTION 41
21681
12
# OF JOBS
Please tell us about the jobs you have had since August 1, 2006, starting with the most recent and
working backwards.
JOB 2
When did you first start
this job?
Before 2006
2006
2007
2008
2009
2010
Before 2006
2006
2007
2008
2009
2010
42.
When did you last have
this job?
2006
2007
2008
2009
2010
I still work there
2006
2007
2008
2009
2010
I still work there
43.
Where did you work?
Please write down the
name of the company
you worked for and the
full street address of
this workplace.
41.
Knowing the name and
addresses of the places you
work will allow us to evaluate
the impact of air pollution and
other factors in the general
environment on your health.
We will never use this
information for any other
purpose and will never contact
your employer.
NAME OF COMPANY/PLACE OF WORK
NAME OF COMPANY/PLACE OF WORK
STREET #
STREET #
STREET NAME
STREET NAME
APT #
APT #
CITY OR TOWN
CITY OR TOWN
STATE
STATE
ZIP CODE
COUNTY
ZIP CODE
COUNTY
SPACE IS PROVIDED FOR TWO JOBS. IF YOU HAVE HAD MORE THAN TWO JOBS LASTING 12 MONTHS
OR MORE SINCE AUGUST 1, 2006, PLEASE ANSWER THE SAME QUESTIONS FOR EACH JOB AND RECORD
YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
21681
13
Please use a ballpoint pen for this form
JOB 1
JOB 1
44.
On this job, do/did
you usually spend
time…
45.
What was/is your
job title?
46.
47.
What type of
company or
organization
do/did you work
for? (What do
they make or what
services do they
provide?)
JOB 2
Outdoors
Indoors in a basement
Indoors on the ground (first) floor
Indoors on the second floor
Indoors on the third floor or higher
Traveling in a vehicle
(e.g., truck, auto, train, plane)
Outdoors
Indoors in a basement
Indoors on the ground (first) floor
Indoors on the second floor
Indoors on the third floor or higher
Traveling in a vehicle
(e.g., truck, auto, train, plane)
JOB TITLE
JOB TITLE
INDUSTRY
INDUSTRY
JOB DUTIES
JOB DUTIES
What are the
specific tasks that
you usually do/did
in your job?
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14
JOB 1
48.
How many hours
per week do/did
you usually work at
this job?
Less than 10
11-20
21-30
31-40
More than 40
What hours of the
day do/did you
usually work at this
job?
Less than 10
11-20
21-30
31-40
More than 40
(mark one)
:
(hr)
PM
(min)
(mark one)
:
PM
OR
How many times
per month do/did
you work at night?
“Work at night”
means any shift
that includes at
least one hour
between midnight
and 2:00 AM.
AM
PM
(min)
STOP TIME:
(mark one)
:
(hr)
AM
(min)
PM
OR
I work(ed) irregular hours
I work(ed) rotating shifts
50.
(hr)
AM
(min)
(mark one)
:
AM
STOP TIME:
(hr)
START TIME:
I work(ed) irregular hours
I work(ed) rotating shifts
Never
1-2 times/month
3-5 times/month
6-10 times/month
Never
1-2 times/month
3-5 times/month
6-10 times/month
11-15 times/month
11-15 times/month
More than 15 times per month
More than 15 times per month
21681
15
Please use a ballpoint pen for this form
START TIME:
49.
JOB 2
JOB 1
JOB 2
NO YES
51.
While working at
this job do/did
you regularly...
NO YES
a. work in dusty conditions?
a. work in dusty conditions?
b. breathe in chemical
vapors or fumes?
b. breathe in chemical
vapors or fumes?
c. get chemicals or oils on
your skin or clothing?
c. get chemicals or oils on
your skin or clothing?
d. come in contact with
solvents or degreasers?
d. come in contact with
solvents or degreasers?
e. come in contact with
metal chips, dust, or
fumes?
e. come in contact with
metal chips, dust, or
fumes?
f. come in contact with
pesticides?
f. come in contact with
pesticides?
g. use cleaning solutions
(not counting dish or
laundry detergents)?
g. use cleaning solutions
(not counting dish or
laundry detergents)?
Please check to see that all questions are answered.
Thank you for completing this questionnaire and for your
continued participation in the Sister Study.
Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: update@sisterstudy.org
21681
16
Form: 35
Vers:
02
ID#: SIS
OMB No. 0925-0522
The Sister Study
c
Stress and Coping
Version 2
Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Do not write comments on the form.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.
Like this:
Not like this:
2 3
If you must change an answer, please mark a single horizontal line through it and bubble in the
correct answer completely.
Like this:
YES
Not like this:
2
YES
Please write responses without touching the sides of the boxes.
Like this:
1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.
EXAMPLE: June 7, 2004 =
0 6 / 0 7 / 2 0 0 4
(month)
(day)
(year)
Public reporting burden for this collection of information is estimated to average 20 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.
National Institute of Environmental Health Sciences / National Institutes of Health / Department of Health and Human Services
38635
1
This one-time survey asks about your experiences and how you have felt at different times in your life.
Some of the questions are about the past week or month and others focus on your entire life. Please pay
careful attention to the time-frame for each question.
Your continued participation in the Sister Study is completely voluntary and greatly appreciated. Some
questions may be personal or sensitive. All of your answers will be kept confidential. You will not be
identified in any way. However, if you are not comfortable answering a question, just skip it and go on to
the next one.
Please mark the category that best describes your response. There are no right or wrong answers. Try not
to let your response to one statement influence your responses to other statements. Answer according to
your own feelings, rather than how you think “most people” would answer. Don’t take too long thinking
over your replies; your immediate reaction will probably be more accurate than a long thought out
response.
/
Today's Date:
(month)
/
2
(day)
0
(year)
1. How often during the past 30 days, have you...
Never
Almost
Never
Sometimes
Fairly
often
Very
often
a. ...felt that you were unable to control the
important things in your life?
b. ...felt confident about your ability to handle
your personal problems?
c. ...felt that things were going your way?
d. ...felt difficulties were piling up so high that
you could not overcome them?
38635
2
2. For each statement below, choose the answer that best indicates how often the statement
is true for you.
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of
the time
a. I can count on someone to provide me
with emotional support (someone to
confide in about myself or a problem or
who will listen to me when I need to talk).
Please use a ballpoint pen for this form
b. I can count on someone if I need help (for
example, to take me to the doctor or help
with daily chores if I am sick).
c. There is someone in my immediate family
who believes in me and wants me to
succeed.
d. There is someone in my immediate family
who makes me feel important or special.
e. When I was a child, there was someone in
my immediate family who believed in me
and wanted me to succeed.
f. When I was a child, there was someone in
my immediate family who made me feel
important or special.
3. In general, how many relatives or friends do you feel close to (people you feel at ease with,
can talk to about private matters, or call on for help)?
NONE
1-2
3-5
6-9
10 or more
38635
3
4. During the past 12 months, about how many hours per week on average did you provide care for
children or grandchildren?
NONE
GO TO QUESTION 5
1-8 hours
4a.
9-20 hours
21-40 hours
41 or more hours
4b.
How stressful would
you say it is to provide
care for these children
or grandchildren?
Not at all
During the past 12 months,
for whom did you provide
such care? (Please mark all
that apply.)
My children
A little
A moderate amount
A lot
My grandchildren
Other children
5. During the past 12 months, about how many hours per week on average did you provide care for a
disabled or ill parent, child, sibling, spouse, partner, or other relative?
NONE
GO TO THE NEXT PAGE, QUESTION 6
1-8 hours
9-20 hours
5a.
21-40 hours
41 or more hours
5b.
How stressful would
you say it is to provide
care for these disabled
or ill individuals?
Not at all
During the past 12
months, for whom did
you provide such care?
(Please mark all that
apply.)
Parent
Child
Sibling
Spouse
Partner
Other relative
A little
A moderate amount
A lot
38635
4
6. There are many ways to deal with problems. These items ask what you do, in general, to cope with
the stress in your life. To what extent do you do the following?
Not at all
A little
A moderate
amount
A lot
a. I get emotional support or comfort and
understanding from others.
b. I give up trying to deal with things or trying to cope.
c. I take action to try to make the situation better.
Please use a ballpoint pen for this form
d. I refuse to believe that things have happened.
e. I criticize or blame myself.
f. I express my negative feelings.
g. I learn to live with things.
h. I try to laugh or make fun of the situation.
i. I try to grow as a person from the experience.
7. How important is your religious faith or spirituality to you?
Not at all
A little
A moderate amount
A lot
8. How much is religion or spirituality a source of strength and comfort to you?
Not at all
A little
A moderate amount
A lot
9. How often do you pray or meditate?
Never
Less than once a year
Yearly or a few times a year
Monthly or a few times per month
1 to 3 times per week
4 to 6 times per week
Every day
38635
5
10.Please read each statement below and mark the one response that best matches how you feel.
Strongly
disagree
Disagree
Neither
agree nor
disagree
Agree
Strongly
agree
a. In uncertain times, I usually expect the best.
b. If something can go wrong for me, it will.
c. I’m always optimistic about my future.
d. I hardly ever expect things to go my way.
e. I rarely count on good things happening to me.
f. Overall, I expect more good things to happen
to me than bad.
11. Below is a list of some of the ways you may have felt or behaved. During the past week, how
often did you feel or act this way?
Rarely or
none of
the time
A little
of the
time
A moderate
amount of
the time
Most or
all of
the time
a. I was bothered by things that usually don’t bother me.
b. I had trouble keeping my mind on what I was doing.
c. I felt depressed.
d. I felt that everything I did was an effort.
e. I felt hopeful about the future.
f. I felt fearful.
g. My sleep was restless.
h. I was happy.
i. I felt lonely.
j. I could not “get going.”
38635
6
The next questions are about personal experiences that may have happened at any time in your life.
Think about how old you were when reporting when these experiences took place.
a.
IF YES, this
happened...
(Mark all that apply.)
NO
13. Have you ever been in a major accident
involving a car or other vehicle, or a
work site accident that resulted in
serious injury to yourself or the fear
of your own death, or serious injury
or death of someone with whom you
were very close?
14. Have you ever been deliberately hit or
attacked so severely as to result in
marks, bruises, burns, blood, or broken
bones by someone with whom you
were very close?
15. Have you ever been deliberately hit or
attacked so severely as to result in
marks, bruises, burns, blood, or broken
bones by someone with whom you
were not so close?
16. Have you ever been made to have
unwanted sexual contact, such as
touching or penetration by someone
with whom you were very close?
17. Have you ever been made to have
unwanted sexual contact, such as
touching or penetration by someone
with whom you were not so close?
18. Have you ever been emotionally or
psychologically mistreated (such as
being yelled or screamed at, insulted or
belittled) over a significant period of
time by someone with whom you were
very close?
at age 12 or younger
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
38635
7
Please use a ballpoint pen for this form
12. Have you ever been in a major fire,
flood, or other natural disaster that
resulted in serious injury to yourself
or the fear of your own death, or
serious injury or death of someone
with whom you were very close, or
serious damage to your home?
YES
b.
Regardless of when
this happened, how
much distress or
anxiety has this
caused you in the
past 4 weeks?
a.
IF YES, this
happened...
(Mark all that apply.)
NO
19. Have you ever been emotionally or
psychologically mistreated (such as
being yelled or screamed at, insulted
or belittled) over a significant period
of time by someone with whom you
were not so close?
20. Have you ever personally witnessed
someone with whom you were very
close committing suicide, or being
attacked so severely as to result in
marks, bruises, burns, blood, broken
bones or teeth, or death?
21. Have you ever personally witnessed
someone with whom you were not so
close committing suicide, or being
attacked so severely as to result in
marks, bruises, burns, blood, broken
bones or teeth, or death?
22. Have you ever personally witnessed
someone with whom you were very
close deliberately attack another
family member so severely as to result
in marks, bruises, burns, blood,
broken bones or teeth?
23. Have you ever personally witnessed or
learned of your own child’s experience
of unwanted sexual contact, sexual
abuse, physical or psychological abuse?
24. Have you ever experienced the death
of a spouse?
25. Have you ever experienced the death
of your child?
YES
at age 12 or younger
no
yes
no
yes
no
yes
no
yes
no
yes
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
before age 18
none
a little
age 18 to last year
in the past 12 months
before age 18
no
yes
age 18 to last year
in the past 12 months
before age 18
no
yes
b.
Regardless of when
this happened, how
much distress or
anxiety has this
caused you in the
past 4 weeks?
age 18 to last year
in the past 12 months
a moderate amount
a lot
none
a little
a moderate amount
a lot
none
a little
a moderate amount
a lot
38635
8
a.
IF YES, this
happened...
(Mark all that apply.)
NO
YES
at age 12 or younger
27. Have you ever experienced the
death of a parent?
28. Have you ever experienced the
death of a close personal friend?
29. Have you ever personally experienced
a major illness (life threatening or
severely disabling to you)?
30a.
no
yes
no
yes
no
yes
no
yes
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
Thinking about breast cancer in some of your blood relatives, how old were you when you
had a sister diagnosed with breast cancer? (Mark all that apply.)
Age 12 or younger
Age 13 to age 17
Age 18 to last year
In the past 12 months
30b.
Regardless of when this happened, how much distress or anxiety has this caused you in the
past 4 weeks?
None
A little
A moderate amount
A lot
38635
9
Please use a ballpoint pen for this form
26. Have you ever experienced the
death of a sibling?
b.
Regardless of when
this happened, how
much distress or
anxiety has this
caused you in the
past 4 weeks?
a.
IF YES, this
happened...
(Mark all that apply.)
NO
YES
at age 12 or younger
31. Have you ever experienced your
mother getting breast cancer?
32. Have you ever experienced a
daughter of yours getting breast
cancer?
33. Have you ever experienced a major
illness other than breast cancer (life
threatening or severely disabling) in
someone close to you?
34. Have you ever experienced a major
change in, or serious difficulty with
a personal relationship (such as a
divorce, or child custody issues)?
35. Have you ever experienced serious
financial or legal troubles such as
arrest or bankruptcy (either you or
another family member whose
troubles would directly affect you)?
36. Have you ever experienced serious
family problems related to alcohol,
drug, or other substance abuse, or
mental illness (either you or
another family member whose
troubles would directly affect you)?
37. Have you ever experienced a seriously
traumatic event not already covered
in any of these questions?
no
yes
no
yes
b.
Regardless of when
this happened, how
much distress or
anxiety has this
caused you in the
past 4 weeks?
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 18 to last year
none
a little
in the past 12 months
a moderate amount
a lot
at age 12 or younger
no
yes
no
yes
no
yes
no
yes
no
yes
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
at age 12 or younger
at age 13 to age 17
none
a little
at age 18 to last year
a moderate amount
in the past 12 months
a lot
38635
10
38.People may be frightened of being a victim of violence due to where they live or work. About
how often were you afraid of being personally attacked or injured...
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of
the time
a. ...as a child?
b. ...as a teen?
39.Please choose the answer that best describes how you feel about safety these days.
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of
the time
a. Nowadays, I worry about my personal
safety.
b. Nowadays, I feel heightened tension when
I am in crowded places.
c. I am afraid of a terror strike harming
me or my family.
38635
11
Please use a ballpoint pen for this form
c. ...as an adult?
a.
NO
YES
40. Have you ever been treated unfairly in home renting,
buying, or mortgage due to your race or ethnicity?
no
yes
41. Have you ever been treated unfairly in being stopped,
searched, or threatened by police due to your race or
ethnicity?
no
yes
42. Have you ever been treated unfairly in receiving service
at a store or restaurant due to your race or ethnicity?
no
yes
43. Have you ever been treated as though you were less
intelligent, worthy, or honest than others due to your
race or ethnicity?
no
yes
44. Have you ever experienced people acting as if they are
afraid of you due to your race or ethnicity?
no
yes
45. Have you ever felt discriminated against because of your
sexual orientation?
no
yes
46. Have you ever been treated unfairly in home renting,
buying, or mortgage due to your sexual orientation?
no
yes
47. Have you ever been treated unfairly in receiving service
at a store, restaurant or other place of business due to
your sexual orientation?
no
yes
IF YES, has this
happened in the
past five years?
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
38635
12
The following questions are about how you have been treated at work.
48. Have you ever held a full-time or part-time job other than homemaking that took at least 10
hours per week, where you worked for one year or longer?
No
GO TO END, PAGE 16
Yes
NO
YES
49. Have you ever been treated unfairly in job hiring,
promotion or firing due to your sex?
no
yes
50. Have you ever been treated unfairly in job hiring,
promotion or firing due to your age?
no
yes
51. Have you ever been treated unfairly in job hiring,
promotion or firing due to your race or ethnicity?
no
yes
52. Have you ever been treated unfairly in job hiring,
promotion or firing due to your sexual orientation?
no
yes
53. Have you ever been treated unfairly in job hiring,
promotion or firing due to an illness or medical condition?
no
yes
IF YES, has this
happened in the
past five years?
no
yes
no
yes
no
yes
no
yes
no
yes
38635
13
Please use a ballpoint pen for this form
a.
54. The following questions are about possible mistreatment at work.
No
Yes
Not
applicable
a. In the past 12 months, have you been repeatedly mistreated,
harassed, or otherwise prevented from doing your job
successfully?
b. Have you been repeatedly mistreated, harassed, or otherwise
prevented from doing your job successfully at any other time
in your working life?
c. Have you ever lost, quit, or otherwise changed your job as a
result of being mistreated or harassed on the job?
d. Have you ever had to seek medical or professional help as a
result of being mistreated or harassed on the job?
38635
14
The next questions are about your current or most recent jobs, not including volunteer work.
55. Thinking about your current (or most recent) job(s), indicate how much you agree or disagree
with the following statements.
Strongly
disagree
Neither
agree nor
Disagree disagree
Agree
Strongly
agree
a. My job requires that I learn new things.
Please use a ballpoint pen for this form
b. My job requires me to be creative.
c. My job requires working very fast.
d. My job requires working very hard.
e. My job involves a lot of repetitive work.
f. My job allows me to make a lot of decisions.
g. My job requires a lot of skill.
h. On my job I have very little freedom to decide how to
do my work.
i. I get to do a variety of things on my job.
j. I have a lot of say about what happens on my job.
k. I have an opportunity to develop my own special abilities.
l. I am not asked to do an excessive amount of work.
m. I have enough time to get my job done.
n. I am free from conflicting demands that others make.
o. My job security is good.
p. My prospects for career development and promotions
are good.
q. In five years my skills will still be valuable.
38635
15
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of
Not
the time applicable
56. In the past 12 months, how
often have the demands of your
job interfered with your family
life?
57. In the past 12 months, how often
have the demands of your family
life interfered with your work on
the job?
58. In the past 12 months, have you had to quit, reduce your hours, or change your job in order to
meet the needs of your family life?
No
Yes
Not applicable
Please check to see that all questions are answered.
Thank you for completing this questionnaire and for your
continued participation in the Sister Study.
Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: update@sisterstudy.org
38635
16
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 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 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: update@sisterstudy.org
National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services
Biennial Follow-up
Reminder Letter
Date
FirstName LastName
Mailing Address 1
Mailing Address 2
City, State Zip
Dear Ms. Last Name:
We have not yet received your Sister Study Follow-Up forms. Finding out about changes in your health
and exposures will allow us to learn what environmental and lifestyle factors contribute to developing
breast cancer and other conditions. We recently sent you update forms about your Health and Medical
History, Lifestyle and Environment, and Stress and Coping, along with a Contact Information Update Form.
Please take some time to complete your forms within the next few days.
You can also complete these updates over the telephone by calling the Sister Study helpdesk tollfree at 1-877-4SISTER (1-877-474-7837).
Information you share will be kept co nfidential. Y our participat ion in the Sister Study is completely
voluntary and you may choose to ski p questions or stop at any time. If you have already returned your
forms, please accept our thanks for your continued participation in the Sister Study.
Woman by woman, sister by sister, we can make a difference.
Sincerely,
Dale P. Sandler, Ph.D.
Principal Investigator
Biennial Follow-up
Telephone Prompt
1. Hello Ms. LAST NAME, my name is… and I am calling on behalf of the Sister Study. We recently
sent you a package containing a newsletter and questionnaires about your Health and Medical History,
Lifestyle and ENvironment, and Stress and Coping. Do you remember receiving this?
NO
YES
GO TO 5
GO TO 2
2. We are calling because we have not y et received your completed biennial 200[N] forms.
While your participation is voluntary, i t is important that women in the Sister Study com plete
these forms so we can learn how the environmental and lifestyle factors you already told us about
affect changes in health, including why some women develop breast cancer. We hope you will
complete these forms soon. You can complete them over the phone now or at a more convenient
time or you can complete them yourselves and return them by mail. Will you be able to complete
the updates now or some time soon?
3.
NEEDS A REMAIL
GO TO 5
ALREADY RETURNED
Thank you very much - CODE MAIL, GO TO 7
WILL DO OR NOT SURE
GO TO 3
WILL DO INTERVIEW NOW GO TO INVITATION FOR TELEPHONE
INTERVIEW, #2
WILL SET APPOINTMENT DETERMINE CALLBACK TIME, RECORD IN
COMMENTS
PARTICIPANT WILL NOT DO FOLLOW-UP Thank you for your past
participation. If you change your mind, please feel
free to contact us. GO TO UPDATE CONTACT
INFORMATION
PARTICIPANT REFUSE S ALL FUTURE CONTACT Thank you f or your past
participation. If you change your mind, please feel
free to contact us.
3. Do you still have the forms we sent?
NO
YES
GO TO 5
GO TO 4
4. We would appreciate if you could complete the forms and return them as soon as possible in
the postage-paid envelope that was provided . We'll hope to receive your questionnaires in the next
few weeks. We may call you in a few weeks if they haven't arrived. ANSWER QUESTIONS AS
NEEDED. CODE WILL MAIL, GO TO 7
[IF FORMS ARE NOT RECEIVED, CALLBACK WILL BE MADE 14 DAYS LATER]
5. We can send you a new package.
GO TO 6
6. CONFIRM OR CORRECT MAILING ADDRESS ON LABEL. We will send a new package to
you in the next few days. We would appreciate if y ou could take some time to complete th e
forms and return them in the p ostage-paid envelope that is provided. CODE REMAIL,
GO TO 7
7. At this time, we would like to update your (other) contact information. Have th ere been any changes
to your:
Name
Mailing address
Street address
Any of your phone numbers
Any email address
MAKE CORRECTIONS AS NEEDED.
Also, have there been any changes to the information for the contact people you provided? PROMPT
FOR NAME, RELATIONSHIP, ADDRESS, PHONE NUMBER
Thank you for your help. Next year, we will need only a brief update on your contact information and
health, similar to what you received last year. If anything changes in the meantime, you can update
your contact inform ation by sending an email to update@sisterstudy.org or by calling the Sister
Study helpdesk toll-free at 1-877-4SIST ER (1-877-474-7837). When you call or email us, it will be
helpful to give your Sister Study ID number, which is …
You can always visit our website at www.sisterstudy.org for more news about the Sister Study.
Thank you again for contributing to this important research.
Biennial Follow-up
Invitation for &RPSOHWLRQE\Telephone
1. Hello Ms. LAST NAME, my name is… and I am calling on behalf of the Sister Study. We recently
sent you a package containing a newsletter and forms about your Health and Medical History, Lifestyle
and Environemtn, and Stress and Coping. We have not y et received your completed forms so we are
calling to ask if you would help by taking some time to answer these questions with us now over the
phone.
YES
GO TO 2
NOT A GOOD TIME NOW
DETERMINE CALLBACK TIME, RECORD IN
COMMENTS
ALREADY RETURNED
Thank you very much. We'll hope to receive your
forms in the next week or so. We may call you
in a couple of weeks if they still haven’t arrived. Goodbye. [IF FORMS ARE NOT RECEIVED, CALLBACK
WILL BE MADE 10 DAYS LATER]
PARTICIPANT WILL NOT DO FOLLOW-UP Thank you for your past participation. If you
change your mind, please feel free to contact us. GO TO
UPDATE CONTACT INFORMATION
PARTICIPANT REFUSES ALL FUTURE CONTACT Thank you for your past
participation. If y ou change your mind, please f eel free
to contact us.
2. PROCEED TO HEALTH FORM.
WHEN ALL FORMS COMPLETE, GO TO 3
3. Thank you for co mpleting these updates. At this time, we would like to update your contact
information. Have there been any changes to your:
Name
Mailing address
Street address
Any of your phone numbers
Any email address
MAKE CORRECTIONS AS NEEDED.
Also, have there been any changes to the information for the contact people you provided? PROMPT
FOR NAME, RELATIONSHIP, ADDRESS, PHONE NUMBER
Thank you for your help. Next year, we will need only a brief update on your contact information and
health, similar to what you received last year. In the meantime, if anything changes you can update
your contact information by sending an email to update@sisterstudy.org or by calling the Sister
Study helpdesk toll-free at 1-877-4SIST ER (1-877-474-7837). When you call or email us, it will be
helpful to give your Sister Study ID nmber, which is … You can always visit our website at
www.sisterstudy.org for more news about the Sister Study. Thank you again for contributing to this
important research.
| File Type | application/pdf |
| File Title | Microsoft Word - SIS_HealthUpdateForm_y1v5_20090319.doc |
| Author | armsbyp |
| File Modified | 2009-08-20 |
| File Created | 2009-03-19 |