Form 1 PSE-Participant Safety Screen

Public reporting burden for this collection of information is estimated to average 02
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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2 Participant Safety Screening Form
FORM CODE: PSE
VERSION: 1, 12/10/2013

ID
NUMBER:

Contact
Occasion

0

2

SEQ #

0

1

ADMINISTRATIVE INFORMATION

/

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

/

0b. Staff ID:

Instructions: This safety screening form must be completed before the participant can have their Baseline
Examination either during a reminder phone call for the clinic visit, or immediately prior to the exam. Positive responses
to Questions 2 – 6 should be noted on the Exam Itinerary Checklist for routing purposes during the visit.

NOTE TO STAFF: Use appropriate clinic scheduling script when completing this form.
A. Safety and Access Questions
1. FEMALES only: Are you pregnant? [MUJERES solamente: ¿Está embarazada?]
No

0
 STOP, reschedule visit after delivery

Yes 1

2. Do you need any kind of assistance reading, hearing questions, or getting on an examination table?
[¿Necesita algún tipo de ayuda para leer, escuchar preguntas o para subirse a una camilla de
reexaminación ?]
No

 GO to Question 3

0

 GO to Question 2a

Yes 1

2a. Specify: _____________________________
3. Do you have either a heart pacemaker or defibrillator (AICD)?
[¿Tiene un marcapaso o defribilador (AICD por sus siglas en inglés?]
No

0
 Exclude from BIA 

Yes 1

4. Has a doctor or health professional ever told you that you have diabetes (high sugar in blood or urine)?
[¿Alguna vez le ha dicho un doctor que usted tiene diabetes (azúcar alta en la sangre o en la orina)?]
No

0

Yes

1

 Exclude from OGTT 

PSE-Participant Safety Screen_12-10-13-Bilingual.doc

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ID NUMBER:

FORM CODE: PSE
VERSION: 1, 12/10/2013

Contact
Occasion

0

2

SEQ #

B. Echocardiography Exam Exclusion Questions
5. Did this person participate in the HCHS Echo ancillary study?
No 0
 Echo Exam Exclusion 
Yes 1
C. Other Exclusion(s)
6. Specify condition or circumstance: _________________________________________
6a. Procedure(s)/test(s) excluded: _____________________________________
6b. Name or Staff ID authorizing this exclusion:

_______________

Record ALL Yes responses to Questions 2-6 on the Exam Itinerary Checklist form

PSE-Participant Safety Screen_12-10-13-Bilingual.doc

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