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Version Date: 11/99 Expiration Date: 07/05,Form Approved OMB#: 0925-0407
"Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial",
ANNUAL STUDY UPDATE (ASU),
Participant ID: FIELD(9) *FIELD(11)*,"November 23, 1998"
*FIELD(12)*,
Participant Name: FIELD(10),Study Year: FIELD(13)
"If Your Name (Printed Above) Is Incorrect, Please Record Your Corrected Name Below.",
Corrected Name: ____________________________________,
"1. In the period from FIELD(14) to the present, have you",Yes []
been diagnosed with cancer by a health care provider?,No []
(Do not include basal-cell or squamous-cell skin cancers.),"(If no, men go to item 3; women go to item 4)"
2. What type of cancer was diagnosed? (Please record all cancers diagnosed during this period except basal-,
cell and squamous-cell skin cancers.),
"Type/Site of Cancer (breast, lung, etc) Date of Diagnosis Hospital or clinic where the cancer was diagnosed",
_____/______/____,
_____/______/____,
_____/______/____,
"What is the name, phone number and address of the physician who diagnosed the most recent cancer?",
Name:______________________________________Phone: (____)_______________________,
Address:________________________________________________________________________,
"",
"3. FOR MEN ONLY: In the period from FIELD(15) to the present, have you taken the medication",
Proscar or Propecia (Finasteride)? Yes [],No []
"",
4. Today’s Date: ______/_______/______,
Month DayYear,
5. Who completed this questionnaire? (Please check one),
[] Study Participant [] Spouse [] Someone else (SPECIFY)_______________________,
"",Relationship
6. Comments:,
___________________________________________________________________________________,
_________________________________________________________________________________________,
Thank you for completing this questionnaire. Please return this form in the enclosed envelope,
"",
"Public reporting burden for this collection of information is estimated to average 5 minutes per response, including 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 Branch",
"Office, 6705 Rockledge Drive, MSC 7974 Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.",
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