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pdfPublic reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining 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 208927974, ATTN: PRA (0925-0281). Do not return the completed form to this address.
OMB#: 0925-0281
Exp. 03/31/2014
SEMI-ANNUAL FOLLOW-UP
CORE QUESTIONS
ID
NUMBER:
FORM CODE:
S
A
F
DATE: 11/19/13
Version 2.0
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
Instructions: This form is completed during the six-month follow up to the participant's annual follow-up interview.
The Date is the day the contact is made, or is the date the status determination is made. Special missing values
are allowed for cases where the response “Don’t know”, “Refused”, “Unknown”, or “N/A” is not listed as an option.
INTRODUCTION SCRIPT: "Hello, this is [your name] from the ARIC Study. May I please speak
with [name of contact]?"
"Hello [name of respondent]. My name is [your name] and I am from the ARIC Study. May I have
a few minutes of your time to ask about your recent health? "
A. STATUS
1. Result of contact for the interview (select one)
a. Participant contacted, agreed to be interviewed...
b. Participant contacted, refused to be interviewed ..
c. Proxy/Informant contacted ...................................
d. Other person contacted .......................................
e. Contact pending; continue to attempt to contact ..
f. Window closed; unable to contact ........................
GO TO QUESTION 2a
GO TO QUESTION 33
SAVE AND CLOSE FORM
SAVE AND CLOSE FORM
2. Is the participant deceased?
Yes ............................
GO TO QUESTION 33, COMPLETE THE DEC FORM
No .............................
GO TO QUESTION 3
B. CANCER INFORMATION
Semi-Annual Follow-Up Core Questions (SAF)
Page 1 of 8
2a. Since we last contacted you, has a doctor said you had cancer?
Yes ............................
No .............................
GO TO QUESTION 10
2a1. Can you tell me in what part of the body the most recently diagnosed cancer was located?
______________________________
2b. What is the approximate date the cancer was diagnosed?
/
Month
Year
DOCTOR INFORMATION FOR CANCER
“Please provide the contact information of the doctor you most recently visited for your
cancer.”
2c. Contact information of the doctor you last saw for your cancer:
2c1. Doctor Name: _________________________
2c2. Clinic or Institution Name: _________________________
2c3. Address: ____________________________
2c4. City: _______________
2c5. State:
/
2c6. Approximate date:
Month
Year
“The ARIC study would like to ask your health care providers to tell us more about your
cancer diagnosis and treatment. If you agree to do this, I will send you a form that tells your
providers that you authorize the ARIC study to get this information from them. Once you sign
that form and mail it back to me, I will contact your health care providers.”
2d. May I send you this release form and an addressed envelope for you to mail it back?
Yes ............................
No .............................
GO TO QUESTION 10
GO TO QUESTION 10
C. CARDIOVASCULAR EVENTS
3. May I ask you some questions about [name’s] health?
Yes .......
No .........
GO TO QUESTION 10
Semi-Annual Follow-Up Core Questions (SAF)
Page 2 of 8
3a. Is there someone else we can ask?
Yes, person located..........................................
Yes, reschedule remainder of interview ............
No ....................................................................
GO TO QUESTION 10
GO TO QUESTION 33
GO TO QUESTION 33
[QUESTIONS 4-9b MOVED TO MCU FORM]
RECENT HEART ATTACK
10. Since we last contacted you [name] on [mm/dd/yyyy], has a doctor said you [name] had a heart
attack?
Yes ............................
No .............................
GO TO QUESTION 14
11. Were you (Was [name]) hospitalized at that time?
Yes ............................
No .............................
GO TO QUESTION 14
Hospital information for heart attack
▼
12a. Hospital Name, City, State:
12a1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
12b. Approximate date of hospitalization
Month
Year
Second hospitalization, if applicable
▼
13a. Hospital Name, City, State:
13a1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
13b. Approximate date of hospitalization
Month
Year
RECENT HEART SYMPTOMS OR STROKE
14. Since we last contacted you [name], has a doctor said you [name] had angina, angina pectoris or
chest pain due to heart disease?
Yes ............................
No .............................
[QUESTION 15 MOVED TO MCU FORM]
Semi-Annual Follow-Up Core Questions (SAF)
Page 3 of 8
15a. Since we last contacted you [name], has a doctor said that you [name] had a blood clot in your
lungs or a pulmonary embolus?
Yes ............................
No .............................
GO TO QUESTION 16
15b. Were you (was [name]) hospitalized for a blood clot in your lungs or a pulmonary embolus at that
time?
Yes ............................
No .............................
GO TO QUESTION 16
HOSPITALIZATION FOR BLOOD CLOT IN LUNGS
▼
15c. Hospital Name, City, State:
15c1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
15d. Approximate date of hospitalization
Month
Year
16. Since we last contacted you [name], has a doctor said that you [name] had a stroke, slight stroke,
transient ischemic attack, or TIA?
Yes ............................
No .............................
GO TO QUESTION 19
17. Were you [was name] hospitalized for this stroke, slight stroke, transient ischemic attack, or TIA?
Yes ............................
No .............................
GO TO QUESTION 19
Hospitalization for stroke or TIA
▼
18a. Hospital Name, City, State:
18a1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
18b. Approximate date of hospitalization
Month
Year
D. OTHER ADMISSIONS
19. Since our last contact, were you (was [name]) hospitalized or did you [name] stay in a hospital
observation unit for any reason that you have not yet mentioned?
Yes ............................
No .............................
GO TO QUESTION 25
HOSPITALIZATION FOR OTHER REASON
20a. Hospitalization Reason: _______________________________
Semi-Annual Follow-Up Core Questions (SAF)
Page 4 of 8
▼
20b. Hospital Name, City, State:
20b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
20c. Approximate date of hospitalization
Month
Year
HOSPITALIZATION FOR OTHER REASON
21a. Hospitalization Reason: _______________________________
▼
21b. Hospital Name, City, State:
21b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
21c. Approximate date of hospitalization
Month
Year
HOSPITALIZATION FOR OTHER REASON
22a. Hospitalization Reason: _______________________________
▼
22b. Hospital Name, City, State:
22b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
22c. Approximate date of hospitalization
Month
Year
HOSPITALIZATION FOR OTHER REASON
23a. Hospitalization Reason: _______________________________
▼
23b. Hospital Name, City, State:
23b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
23c. Approximate date of hospitalization
Month
Year
HOSPITALIZATION FOR OTHER REASON
24a. Hospitalization Reason: _______________________________
24b. Hospital Name, City, State:
▼
24b1. Specify hospital name, city, and state if not in drop down list: _____________________________
Semi-Annual Follow-Up Core Questions (SAF)
Page 5 of 8
/
24c. Approximate date of hospitalization
Month
Year
EMERGENCY ROOM OR OUTPATIENT CARE
25. Were you (Was [name]) seen at an emergency room or a medical facility for outpatient treatment
since our last contact on [mm/dd/yyyy]?
Yes ............................
No .............................
GO TO QUESTION 28
26. Was this related to a heart problem or difficulty breathing?
Yes ............................
No .............................
GO TO QUESTION 28
Emergency room/medical facility information
▼
27a. ER/Facility Name, City, State:
27a1. Specify ER/Facility name, city, and state if not in drop down list:___________________________
/
27b. Approximate date
Month
Year
28. Since our last contact, (Did [name] stay) have you stayed overnight as a patient in a nursing home?
Yes ............................
No .............................
29. Are you (Is [name]) currently a resident of a nursing home or long-term care facility?
Yes ............................
No .............................
E. INVASIVE PROCEDURES
Next I am going to ask about various types of surgery and medical procedures. We are interested
in those that occurred in the hospital, or as an outpatient.
30. Since we last contacted you [name] on [mm/dd/yyyy], have you (did [name]) had any surgery on
your [name’s] heart, or the arteries of your [name’s] neck or legs, not counting surgery for varicose
veins?
Yes ............................
No .............................
GO TO QUESTION 32
31. Did you [name] have:
a. Coronary bypass?
Yes ............................
No .............................
Semi-Annual Follow-Up Core Questions (SAF)
Page 6 of 8
b. Other heart procedure?
Yes ............................
No .............................
Specify: ________________________________________
c. Carotid endarterectomy?
Yes ............................
No .............................
GO TO QUESTION 31e
d. Site:
Right ..........................
Left ............................
Both ...........................
e. Other arterial revascularization?
Yes ............................
No .............................
Specify: ________________________________________
f. Any other type of surgery on your heart or the arteries of your [name’s] neck or legs?
Yes ............................
No .............................
32. Since we last contacted you [name] on [mm/dd/yyyy], have you (has [name]) had a balloon
angioplasty or stent on the arteries of your [name’s] heart, neck, or legs?
Yes ............................
No .............................
IF QUESTION 1 is ‘a. Participant contacted, agreed to be interviewed’,
GO TO QUESTION 33, COMPLETE THE MCU AND GENERAL
INTERVIEW FORM;
IF QUESTION 1 is ‘c. Proxy/Informant contacted’, or ‘d. Other person
contacted’, GO TO QUESTION 33, COMPLETE THE MCU
Did you [name] have:
a. Angioplasty or stent of the coronary arteries of your [name’s] heart?
Yes ............................
No .............................
b. Angioplasty or stent in the arteries of your [name’s] neck?
Yes ............................
No .............................
c. Angioplasty or stent of the lower extremity arteries?
Yes ............................
No .............................
Angioplasty or stent facility information
d. Facility Name, City, State:
▼
e. Specify Facility name, city, and state if not in drop down list:___________________________
Semi-Annual Follow-Up Core Questions (SAF)
Page 7 of 8
/
f. Approximate date
Month
IF QUESTION 1 is ‘a. Participant contacted, agreed to
Year
be interviewed’, GO TO QUESTION 33, COMPLETE
THE MCU AND GENERAL INTERVIEW FORM;
IF QUESTION 1 is ‘c. Proxy/Informant contacted’
or ‘d. Other person contacted’, GO TO QUESTION 33,
COMPLETE THE MCU
F. ADMINISTRATIVE INFORMATION
33. sAFU Core Questions Completion Status:
a. Complete ....................................................................................
b. Partially complete; contact again within window (interruptions) ...
c. Partially complete; unable to complete within window (done) ......
CLOSURE SCRIPT:
If participant deceased: “We may need to contact a family member later. When would be a good
time to call in that
Semi-Annual Follow-Up Core Questions (SAF)
Page 8 of 8
OMB#: 0925-0281
Exp. 03/31/2014
MEDICAL CONDITIONS UPDATE FORM
ID
NUMBER:
FORM CODE:
M
C
U
DATE:11/19/2013
Version 1.0
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
0c. Person being interviewed:
Participant ........................................
Proxy/informant/Other person ...........
GO TO QUESTION 6
Instructions: This form is updated during the interview portion of the participant's follow-up. Any medical condition
question which has already been answered ‘Yes’ should not be asked. Special missing values are allowed for
cases where the response “Don’t know”, “Refused”, “Unknown”, or “N/A” is not listed as an option.
SECTION I – This section is asked of the participant only
1. Since we last contacted you, has a doctor said you had high blood pressure?
Yes ............................
No .............................
/
1a. Date:
Month
GO TO QUESTION 2
/
Day
Year
1b..CY:
2. Since we last contacted you, has a doctor said you have diabetes or sugar in the blood?
Yes ............................
No .............................
/
2a. Date:
Month
GO TO QUESTION 3
/
Day
Year
2b..CY:
Medical Conditions Update Form (MCU)
Page 1 of 5
3. Since we last contacted you, has a doctor told you that you had chronic lung disease, such as
bronchitis, or emphysema?
Yes ............................
No .............................
/
3a. Date:
Month
GO TO QUESTION 4
/
Day
Year
3b. CY:
4. Since we last contacted you, has a doctor said you had asthma?
Yes ............................
No .............................
/
4a. Date:
Month
GO TO QUESTION 5
/
Day
Year
4b..CY:
5. Since we last contacted you, has a doctor said that you have peripheral vascular disease or
intermittent claudication?
Yes ............................
No .............................
/
5a. Date:
Month
GO TO QUESTION 6
/
Day
Year
5b..CY:
SECTION II – This section is asked of the participant or the proxy/informant/other person
6. Since we last contacted you [name], has a doctor said that you [name] had heart failure or congestive
heart failure?
Yes ............................
No .............................
GO TO QUESTION 7a
7. Since we last contacted you [name], has a doctor said that your [name’s] heart is weak, or does not
pump as strongly as it should, or that you had fluid on the lungs?
Yes ............................
No .............................
/
7a. Date:
Month
GO TO QUESTION 12
/
Day
Year
7b..CY:
Medical Conditions Update Form (MCU)
Page 2 of 5
DOCTOR INFORMATION FOR HEART FAILURE/WEAK HEART
8. Name and address of the doctor you [name] saw:
8a. Name _________________________
8b. Address ____________________________
8c. City: _______________
8d. State:
/
8e. Approximate date:
Month
Year
If speaking to the participant: “The ARIC study would like to ask your doctor to tell us more
about your health. If you agree to do this, I will send you a form that tells your doctor that
you authorize the ARIC study to get this information. Once you sign that form and mail it
back to me, I will contact your doctor’s office.”
If speaking to the proxy/informant/other: “The ARIC study would like to ask [name’s] doctor to
tell us more about his/her health. If you agree to do this, I will send [name] a form that tells
the doctor that [name] authorizes the ARIC study to get this information. Once [name] signs
that form and mails it back to me, I will contact the doctor’s office.”
9. May I send you this release form and an addressed envelope for you to mail it back?
Yes ............................
No .............................
If the participant agrees to receiving and signing the release form, remember to update the PHF form
when the release form is sent to the participant, and then again when the release form is received back.
HOSPITAL INFORMATION FOR HEART FAILURE/WEAK HEART
10. At that time, were you (Was [name]) hospitalized or did you [name] stay in a hospital observation
unit?
Yes ............................
No .............................
GO TO QUESTION 12
▼
11a. Hospital/Medical Facility Name, City, State:
11a1. Specify hospital/medical facility name, city, and state if not in drop down list: _________________
/
11b. Approximate date of admission:
Month
Year
12. Since we last contacted you [name], has a doctor said you [name] had an irregular heart beat called
atrial fibrillation, or atrial fibrillation on a heart scan or electrocardiogram tracing?
Yes ............................
No .............................
Medical Conditions Update Form (MCU)
Page 3 of 5
13. Since we last contacted you [name], has a doctor said that you [name] had a blood clot in a leg or
deep vein thrombosis?
Yes ............................
No .............................
GO TO QUESTION 16a
14. At that time, were you (was [name]) hospitalized or did you [name] stay in a hospital observation
unit for a blood clot in a leg or deep vein thrombosis?
Yes ............................
No .............................
GO TO QUESTION 16a
HOSPITALIZATION FOR BLOOD CLOT IN LEG
▼
15a. Hospital Name, City, State:
15a1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
15b. Approximate date of hospitalization
Month
Year
PERSONAL NEUROLOGIC HISTORY
If speaking to the participant: “Since we last contacted you, have you been told by a doctor or
health professional that you have:”
If speaking to the proxy/informant/other: “Since we last contacted you [name], has [name] been
told by a doctor or health professional that he/she has:”
16a. Alzheimer’s Disease?
Yes ............................
No .............................
/
16a1. Date:
Month
GO TO QUESTION 16b
/
Day
Year
16a2..CY:
16b. Parkinson’s Disease?
Yes ............................
No .............................
/
16b1. Date:
Month
GO TO QUESTION 16c
/
Day
Year
16b2..CY:
Medical Conditions Update Form (MCU)
Page 4 of 5
16c. Memory loss or cognitive impairment?
Yes ............................
No .............................
/
16c1. Date:
GO TO QUESTION 16d
/
Month
Day
Year
16c2..CY:
16d. Dementia, vascular dementia, or hardening of the arteries of the brain?
Yes ............................
No .............................
/
16d1. Date:
Month
SAVE AND CLOSE FORM
/
Day
Year
16d2..CY:
CLOSURE SCRIPT:
If proxy/informant/other person contacted: "Thank you very much for answering these
questions. We will call ______ in a few months."
Medical Conditions Update Form (MCU)
Page 5 of 5
OMB#: 0925-0281
Exp. 03/31/2014
SEMI-ANNUAL FOLLOW-UP
GENERAL INTERVIEW
ID
NUMBER:
FORM CODE:
G
N
DATE: 11/19/2013
Version 1.0
C
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
Instructions: This form is completed during the six-month follow up to the participant’s annual follow-up interview. The
date is the day the contact is made, or is the date the status determination is made. Special missing values are
allowed for cases where the response “Don’t know”, “Refused”, “Unknown”, or “N/A” is not listed as an option.
A. SF-12 HEALTH SURVEY
“This survey asks for your views about your health. Please answer each question by selecting one
of the answers I will mention. If you are unsure about a response, please give the best answer you
can.”
1. In general, would you say your health is:
Excellent 1
Very good
2
Good 3
Fair 4
Poor
5
2. The following questions are about activities you might do during a typical day. Does your health now limit
you in these activities? If so, how much?
Yes,
limited
a lot
Yes,
limited
a little
No, not
limited
at all
a. Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf
1
2
3
b. Climbing several flights of stairs
1
2
3
3. During the past 4 weeks, how much of the time have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Accomplished less than you would like
1
2
3
4
5
b. Were limited in the kind of work or other
activities
1
2
3
4
5
Semi-Annual Follow- Up General Interview (GNC)
Page 1 of 3
4. During the past 4 weeks, how much of the time have you had any of the following problems with your
work or other regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Accomplished less than you would like
1
2
3
4
5
b. Did work or other activities less carefully
than usual
1
2
3
4
5
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
Not at all
1
A little bit
2
Moderately
3
Quite a bit
4
Extremely
5
6. These questions are about how you feel and how things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Have you felt calm and peaceful?
1
2
3
4
5
b. Did you have a lot of energy?
1
2
3
4
5
c. Have you felt downhearted and depressed?
1
2
3
4
5
7. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting friends, relatives, etc.)?
All of the time
1
Most of the time
2
Some of the time
3
A little of the time
4
None of the time
5
B. CAREGIVER STATUS
8. Are you currently providing care on an ongoing basis to a family member or friend with a chronic illness
or disability? This would include any kind of help such as watching your family member/friend, dressing or
bathing this person, arranging care, or providing transportation.
Yes ............................
No .............................
GO TO QUESTION 12
9. How are you related to this person?
Spouse .................................
Friend ...................................
Neighbor...............................
Parent/Grandparent ..............
Semi-Annual Follow- Up General Interview (GNC)
Page 2 of 3
10. Do you live with this person?
Yes ............................
No .............................
11. How much mental or emotional strain is it for you to provide this care?
No strain ...............................
Low amount of strain ............
Moderate amount of strain ....
A lot of strain ........................
Extreme amount of strain .....
GO TO QUESTION 15
GO TO QUESTION 15
GO TO QUESTION 15
GO TO QUESTION 15
GO TO QUESTION 15
12. Are you currently receiving care on an ongoing basis from a family member or friend to help with a
chronic illness or disability? This would include any kind of help such as companionship, dressing or
bathing, arranging care, or providing transportation.
Yes ............................
No .............................
GO TO QUESTION 15
13. How are you related to the person who is providing care for you?
Spouse .................................
Friend ...................................
Neighbor...............................
Parent/Grandparent ..............
14. Do you live with this person?
Yes ............................
No .............................
C. ADMINISTRATION INFORMATION
15. sAF General Interview Questions Completion Status:
a. Complete ....................................................................................
b. Partially complete; contact again within window (interruptions) ...
c. Partially complete; unable to complete within window (done) ......
CLOSURE SCRIPT:
"Thank you very much for answering these questions. You have previously provided us with
information on how to contact you. To help us contact you in the future, please tell me if the
information I have is still correct."
[Update the CIU form as necessary.]
"Thank you very much for answering these questions. We will call ______ in about six months."
Semi-Annual Follow- Up General Interview (GNC)
Page 3 of 3
OMB#: 0925-0281
Exp. 3/31/2014
CONTACT INFORMATION UPDATE FORM
ID
NUMBER:
FORM CODE
C
I
U
DATE: 4/20/2011
Version 1.0
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
0c. Does participant have hearing problem/loss? Yes
No
0d. Does participant have cognitive impairment? Yes
No
0e. Participant has a spouse in the ARIC study.
0f. ID number of spouse:
Yes
No
Go to item 0g
0g. Administrative information:______________________________________________________________________
Instructions: This form is updated any time a participant’s information changes.
INTRODUCTION SCRIPT: “Hello Mr/Mrs [name of participant or proxy]. My name is ________. I
would like to verify some of the information we have collected from you [name] in the past. First,
your [name’s] personal information; I’ll read the information we have and you can let me know if
anything needs to be changed."
A. VERIFICATION OF IDENTIFYING INFORMATION
1. a. Title: _____________________________________
b. First Name: ________________________________
c. Middle Name: ______________________________
d. Last Name: ________________________________
2. Mailing Address:
a. _________________________________________
b. _________________________________________
c. City: ______________________________________
d. County: ___________________________________
Contact Information Update Form
Page 1 of 10
e. State:
-
f. Zip Code:
g. Is this mailing address your [name’s] physical address? (i.e. where you [name] live[s])
Yes
No
Go to item 3
Physical Address:
h. _________________________________________
i. __________________________________________
j. City: ______________________________________
k. County: ___________________________________
l. State:
-
m. Zip Code:
3. Home Phone Number:
4. Cell Phone Number:
(
(
)
-
)
(land line)
-
Does not use cell phone
5. Email Address: __________________________________
Does not use email
6. Is there another place where you [name] live[s]?Yes
No
Go to item 9
Mailing Address:
a. _________________________________________
b. _________________________________________
c. City: ______________________________________
d. County: ___________________________________
e. State:
f. Zip Code:
-
7. Phone Number at this second residence:
Contact Information Update Form
(
)
-
Page 2 of 10
8. What time of year do you (does [name])live at this second residence?
from month
to month
-
9. SSN
-
(QxQ: If participant refuses, make field perm. missing)
B. CONTACT PERSON 1
“Now I would like to verify the information we have for your [name’s] contacts. These are the
people we can contact if we are unable to reach you [name] I’ll read the information we have and
you can let me know if anything needs to be changed."
10. a. Title: _____________________________________
b. First Name: ________________________________
c. Middle Name: ______________________________
d. Last Name: ________________________________
11. Mailing Address:
a. _________________________________________
b. _________________________________________
c. _________________________________________
d. City: _____________________________________
-
f. Zip Code:
e. State:
12a. Telephone #1:
(
)
-
b. Telephone #2:
(
)
-
c. Telephone #3:
(
)
-
13. Relationship:
▼
13a. Is this person either the primary or secondary contact? (check only one)
Primary
Secondary
Neither primary nor secondary
C. CONTACT PERSON 2
14. a. Title: _____________________________________
b. First Name: ________________________________
Contact Information Update Form
Page 3 of 10
c. Middle Name: ______________________________
d. Last Name: ________________________________
15. Mailing Address:
a. _________________________________________
b. _________________________________________
c. _________________________________________
d. City: ______________________________________
e. State:
-
f. Zip Code:
16a. Telephone #1:
(
)
-
b. Telephone #2:
(
)
-
c. Telephone #3:
(
)
-
17. Relationship:
▼
17a. Is this person either the primary or secondary contact? (check only one)
Primary
Secondary
Neither primary nor secondary
D. CONTACT PERSON 3
18. a. Title: _____________________________________
b. First Name: ________________________________
c. Middle Name: ______________________________
d. Last Name: ________________________________
19. Mailing Address:
a. _________________________________________
b. _________________________________________
Contact Information Update Form
Page 4 of 10
c. _________________________________________
d. City: ______________________________________
e. State:
-
f. Zip Code:
20a. Telephone #1:
(
)
-
b. Telephone #2:
(
)
-
c. Telephone #3:
(
)
-
21. Relationship:
▼
21a. Is this person either the primary or secondary contact? (check only one)
Primary
Secondary
Neither primary nor secondary
E. FOLLOW-UP PROXY INFORMATION
“We are asking all our ARIC participants to give us the name of a person that can answer questions
about your [name’s] health if you cannot. This person will be considered your [name’s] “follow-up
proxy” for the ARIC Study. Only your ARIC center can contact your [name’s] proxy.”
22. Is one of the contact people you have already identified going to be this person for you [name]?”
Yes
No Go to item 23
22a. Which contact person is your [name’s] follow-up proxy? .............................
1 = Contact #1
2 = Contact #2
3 = Contact #3
Go to item 27
Please identify your [name’s] follow-up proxy.
23. a. Title: _____________________________________
b. First Name: ________________________________
c. Middle Name: ______________________________
d. Last Name: ________________________________
24. Mailing Address:
a. _________________________________________
Contact Information Update Form
Page 5 of 10
b. _________________________________________
c. _________________________________________
d. City: ______________________________________
e. State:
-
f. Zip Code:
(
)
-
(
Telephone #3: (
)
)
-
25a. Telephone #1:
b. Telephone #2:
c.
▼
26. Relationship:
F. PHYSICIAN INFORMATION
Instructions: If updating for Annual Follow-up, this form is complete.
Questions 27 – 32 are asked during the recruitment phone call in preparation for the clinic visit.
“In approximately 6 weeks, we will send you [name] a summary of your study results from this exam
visit.”
27. Would you like us to also send this summary to your [name’s] physician or provider of medical care?
Yes .....
No ...... Go to item 30
28. a. First Name: ________________________________
b. Last Name: ________________________________
29. Mailing Address:
a. Clinic/Building: _____________________________
b. _________________________________________
c. _________________________________________
d. City: _____________________________________
e. State:
f. Zip Code:
Contact Information Update Form
-
Page 6 of 10
G. OPHTHALMOLOGIST OR EYE SPECIALIST INFORMATION
“If you [name is] are selected and agree, we will take a photograph of the back of one of your
[name’s] eyes. If we find a medical condition in your [name’s] eye we can send a report to your
[name’s] eye specialist.”
30. Would you like us to send this report to your [name’s] eye specialist?
Yes .....
No ......
Form is complete
31. What is the name of the doctor, ophthalmologist, or eye specialist you [name] saw concerning your
[name’s] vision?
a. First Name: ________________________________
b. Last Name: ________________________________
32. Mailing Address:
a. Clinic/Building: _____________________________
b. _________________________________________
c. _________________________________________
d. City: _____________________________________
e. State:
f. Zip Code:
Contact Information Update Form
-
Page 7 of 10
CONTACT INFORMATION UPDATE FORM
Appendix 1
AUNT
BROTHER
BROTHER (IN LAW)
BROTHER (STEP)
COUSIN
DAUGHTER
DAUGHTER (IN LAW)
DAUGHTER (STEP)
EX WIFE
FATHER
FATHER (IN LAW)
FATHER (STEP)
FRIEND
GRAND CHILD
HUSBAND
MOTHER
MOTHER (IN LAW)
MOTHER (STEP)
NEIGHBOR
NEPHEW
NIECE
PASTOR/MINISTER/PRIEST
SISTER
SISTER (IN LAW)
SISTER (STEP)
SON
SON (IN LAW)
SON (STEP)
UNCLE
WIFE
OTHER - SPECIFY IN NOTE LOG
Contact Information Update Form
Drop-down menu items for ‘Relationship’ questions on the CIU.
Page 8 of 10
Appendix 2
Follow-Up by Proxy
A very important goal of the Atherosclerosis Risk in Communities (ARIC) Study is to keep track of
any major changes in your health. This information is important for answering scientific questions
about heart disease and other health conditions. You are the best source of information regarding
your health, but there may be times when you are not able to provide these details yourself. We
are asking you to provide us with the name of a person that can answer questions about your
health if you cannot. This person will be considered your “proxy” for the ARIC Study. The person
you designate would only be contacted once per year, should you be unable to respond. Only
your ARIC center can contact your proxy.
What is a proxy?
A proxy is someone who can “stand in” for you and tell us about your health when you cannot
because of illness.
Why is a proxy needed?
For almost 20 years you have been providing information about your health to ARIC. This
important information should not be lost, even when you are unable to provide it yourself.
What does a proxy do?
Should it be necessary we would ask your proxy to answer questions about your health, just like
the questions you have been asked each year by the ARIC staff.
Whom should I name as my proxy?
You should select someone who knows you well enough to provide health information about you.
For example, your proxy can be the person who has your power of attorney, your legal health care
proxy, or your legal next-of-kin (including your spouse, son, daughter, brother, sister, etc).
Am I allowed to change my proxy?
Yes, you may change your proxy at any time by either calling ARIC or by indicating your wishes at
your annual ARIC phone call.
Will you give my earlier information to my proxy?
No, all of your information is strictly confidential and will not be provided to your proxy.
What would you like me to do now?
Using the attached form please indicate whom you have chosen to be your proxy. Please indicate
his/her name, contact information, relationship to you, sign the form and mail it to the ARIC field
center in the enclosed envelope.
We have sent a copy of this form for your own records and one to give to your proxy. This material
should be kept by him/her so he/she understands your wishes as a participant in the ARIC Study.
If you have any questions call Mr/Ms. ……… ARIC Study Manager at (xxx) xxx-xxxx
Contact Information Update Form
Page 9 of 10
Thank you for your continued dedication to the ARIC Study!
ARIC Proxy Designation Form
Participant Name:
________________________________
First
Last
ARIC ID: __________
MI
I have named as my proxy: ________________________________________
(Name of person you choose as ARIC Proxy)
Relationship:________________________________________
Proxy Address:______________________________________
______________________________________
______________________________________
Proxy Phone Number:________________________________
He/she has the authority to provide medical information, and/or to sign a Medical Release Form to
obtain hospital records or physician records for the ARIC Study.
___________________________________
Participant’s Signature
____________
Date
___________________________________
Witness
_____________
Date
Complete only if participant is physically unable to sign: I have signed the Participant’s name above at
his/her direction in the presence of the Participant and witness.
___________________________________
(Name)
________________________________
(Street)
________________________________
(City/Town)
(State)
Optional: If my ARIC Proxy is unwilling or unable to serve, then I appoint as my Alternate ARIC
Proxy:
_______________________________________________________________
(name of person you choose as your alternate proxy)
of______________________________________________________________
(street)
(city/town)
(state)
(phone)
Contact Information Update Form
Page 10 of 10
OMB#: 0925-0281
Exp. 03/31/2014
DEATH INFORMATION
ID
NUMBER:
FORM CODE:
D
E
C
DATE: 12/15/11
Version 1.0
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
0b. Staff ID:
Day
Year
Instructions: This form is completed during the interview portion of the participant’s follow up in the event of the
participant’s death. The Date is the day the contact is made, or is the date the status determination is made.
Special missing values are allowed for cases where the response “Don’t know”, “Refused”, “Unknown”, or “N/A” is
not listed as an option.
INTRODUCTION SCRIPT: "Hello, this is [your name] from the ARIC Study. May I please speak
with [name of contact]?"
"Hello [name of respondent]. My name is [your name] and I am from the ARIC Study. We were
saddened to learn of [participant’s name] death. Please accept our condolences for your
loss. Would you be willing to answer a few questions about [participant’s name]?"
A. DEATH INFORMATION
1. Death reported by: (select one)
Relative/Spouse/Acquaintance ...........................................
Surveillance ........................................................................
Other (e.g., Obituary, Social Security Administration) .........
/
2. Date of death:
Month
/
Day
Year
3. Location of death:
a. City: __________________________
c. State:
b. County: ________________________
Death Information (DEC)
Page 1 of 4
4. Are you able to answer some questions about any hospitalizations that occurred since our last
contact with [name] on [mm/dd/yyyy]?
Yes .....................
No ......................
GO TO QUESTION 6
5. Is there someone else who could answer these questions?
Yes - person located........................................
Yes - reschedule remainder of interview ...........
No ...................................................................
GO TO QUESTION 13
GO TO QUESTION 13
B. HOSPITALIZATIONS FOR HEART ATTACK / HEART CONDITION / STROKE
6. Was [name] hospitalized for a heart attack, or heart condition, or stroke since our last contact on
[mm/dd/yyyy]?
Yes ............................
No..............................
GO TO QUESTION 8
▼
6a. Hospital Name, City, State:
6a1. Specify hospital name, city, and state if not in drop down list: ______________________________
/
6b. Approximate date of hospitalization:
Month
Year
Second hospitalization, if applicable
▼
7a. Hospital Name, City, State:
7a1. Specify hospital name, city, and state if not in drop down list: ______________________________
/
7b. Approximate date of hospitalization
Month
Year
C. OTHER HOSPITALIZATIONS
8. Did [name] stay overnight as a patient in a hospital for any other reason since our last contact?
Yes ............................
No..............................
GO TO QUESTION 11
8a. Hospitalization Reason: _______________________________
8b. Hospital Name, City, State:
▼
8b1. Specify hospital name, city, and state if not in drop down list: _____________________________
Death Information (DEC)
Page 2 of 4
/
8c. Approximate date of hospitalization
Month
Year
Second hospitalization, if applicable
9a. Hospitalization Reason: _______________________________
▼
9b. Hospital Name, City, State:
9b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
9c. Approximate date of hospitalization
Month
Year
Third hospitalization, if applicable
10a. Hospitalization Reason: _______________________________
▼
10b. Hospital Name, City, State:
10b1. Specify hospital name, city, and state if not in drop down list: _____________________________
/
10c. Approximate date of hospitalization
Month
Year
D. OUTPATIENT TREATMENT
11. Was [name] admitted to an emergency room or a medical facility for outpatient treatment since our
last contact?
Yes ............................
No..............................
GO TO QUESTION 13
12. Was this related to a heart problem or difficulty breathing?
Yes ............................
No..............................
GO TO QUESTION 13
▼
12a. Hospital/Medical Facility Name, City, State:
12a1. Specify hospital/medical facility name, city, and state if not in drop down list: _________________
/
12b. Approximate date of admission:
Month
GO TO QUESTION 13
Year
CLOSURE SCRIPT:
"Thank you very much for answering these questions."
Death Information (DEC)
Page 3 of 4
E. ADMINISTRATIVE INFORMATION
13. Death Information Completion Status:
a. Complete ....................................................................................
b. Partially complete; contact again within window (interruptions) ...
c. Partially complete; unable to complete within window (done) ......
Death Information (DEC)
Page 4 of 4
| File Type | application/pdf |
| File Title | Semi-AFU |
| Author | Gerardo |
| File Modified | 2014-03-10 |
| File Created | 2013-11-20 |