Form 1 Annual Study Update

Attachment 1
Annual Study Update Form

*804104-8*

May 22, 2012

Str. ALBERTINE MARGARITA Wiles R.M.
RT 1 BOX 354
3221 GLENDALE AVE
Hopwell PA 15216

ANNUAL STUDY UPDATE

Dear Str. Wiles:

The time for completion of the Annual Study Update (ASU) and the Follow-up Locator Form (FLF) are upon us!
We appreciate the time you have taken in past years to complete these and other study forms. Thank you for
your most important continued participation in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer
Screening Trial. Enclosed are the ASU and FLF forms and a postage-paid envelope in which to return your
completed forms to us.
The ASU form asks questions about your recent health and medical history. Please answer each question to the
best of your ability. The contact information requested on the FLF will help us find you in future years to send
you questionnaires and to notify you of study results. Please update this form with any corrections, and return it
with your ASU. When you have finished completing the forms, please place them in the enclosed postage-paid
envelope, and mail it to PLCO CDCC, 1600 Research Blvd. GA L60, Rockville, MD 20850.
The PLCO Central Data Collection Center (CDCC) will keep any information you give us strictly confidential.
Your name and identifying information will not appear in any study report. All study results will only be reported
in aggregate.
Your continued participation represents a valuable contribution to the PLCO Trial, and we thank you again for
your cooperation. If you have any questions or concerns please call Chris Miller, Participant Support
Coordinator, at our toll-free number, (888) 886-0750.

Sincerely,

Barbara O'Brien, MPH
Project Director, PLCO CDCC

804104-8

PLCO Web site: http://www.cancer.gov/prevention/plco
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Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
ANNUAL STUDY UPDATE and Follow-Up-Form (ASUFLF)

OMB No.: 0925-0407
Expiration Date: XX/XX/20XX

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285 a).
Rights of study participants are protected by the Privacy Act of 1974. Participation is voluntary, and there
are no penalties for not participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The information collected in this study will be held
private to the extent provided by law. Names and other identifiers will not appear in any report of the
study. Information provided will be combined for all study participants and reported as summaries.
You are being contact by mail to complete this instrument so that we can learn about changes in your
health and contact information.
Public reporting burden for this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency
mat 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 (0925-0407). Do not return the completed form to this address.

Version Date: 7/2006
Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
FOLLOW-UP LOCATOR FORM

*804104-8*
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Participant ID:
Study Year:

Today's Date:

/

May 22, 2012

/

Please review the information printed in the left column below to make sure it is correct.
If the information in the left column is correct, check the 'OK' box. Make any additions or corrections
in the right column.

FULL NAME:

OK

FULL NAME:

OTHER LAST NAMES:

OK

OTHER LAST NAMES:

NICKNAME/PREFERRED NAME:

OK

NICKNAME / PREFERRED NAME:

MAIDEN NAME:

OK

MAIDEN NAME:

DATE OF BIRTH:

OK

DATE OF BIRTH:

CURRENT HOME ADDRESS:

OK

HOME ADDRESS/PHONES:

Home Phone:

Work Phone:
Cell Phone:
Email Address:

VACATION HOME/OTHER RESIDENCE:

Phone:
Time of Year:

Home Phone:
Extension

Work Phone:
Cell Phone:
Email Address:

OK

Ext:

VACATION/OTHER ADDRESS/PHONE:

Phone:
Time of Year:

Page 3 of 8

Participant ID:

Study Year:

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ADULT HOUSEHOLD MEMBERS:

ADULT HOUSEHOLD MEMBERS:

Name:

Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

OK

Name:
Relationship:

Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:
Name:

Relationship:

Page 4 of 8

Participant ID:

Study Year:

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PRIMARY CARE PHYSICIAN/CLINIC:

PRIMARY CARE PHYSICIAN/CLINIC:
OK

Fax:

Phone
:
Fax:

Physician Type:

Physician Type:

Phone:

OK

Fax:

Phone
:
Fax:

Physician Type:

Physician Type:

Phone:

OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Phone:

Fax:

Phone
:
Fax:

Page 5 of 8

Participant ID:

Study Year:

*804104-8*
*804104-8*

PRIMARY CARE PHYSICIAN/CLINIC:

PRIMARY CARE PHYSICIAN/CLINIC:

Physician Type:

Physician Type:
OK

Fax:

Phone
:
Fax:

Physician Type:

Physician Type:

Phone:

OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:
OK

Fax:

Phone:

Phone
:
Fax:

Physician Type:

Physician Type:

Page 6 of 8

Participant ID:

Study Year:

*804104-8*
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In the past, you provided us with the names and addresses of the following people who could give us
your new address if you move. It is helpful for us to get the names of people who do not live with
you. Please confirm that these people are the best contacts for you.

CONTACTS:

CONTACTS:
OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

Page 7 of 8

Participant ID:

Study Year:

*804104-8*
*804104-8*

In the past, you provided us with the names and addresses of the following people who could give us
your new address if you move. It is helpful for us to get the names of people who do not live with
you. Please confirm that these people are the best contacts for you.

CONTACTS:

CONTACTS:
OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

OK

Phone 1:
Phone 2:

Phone 1:
Phone 2:

Email Address:

Email Address:

Relationship:

Relationship:

Type:
Type:

Thank you for completing this questionnaire. Please return this form in the enclosed envelope.

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