BQM3_accessible (1).csv

Version Date: 10/99 Expiration Date: 10/02,Form Approved OMB No.: 0925-0407
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Participant ID Number,
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"Prostate, Lung, Colorectal and Ovarian",
Cancer Screening Trial,
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BASELINE QUESTIONNAIRE FOR MALE,
PARTICIPANTS (BQM3),
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PLEASE COMPLETE:,
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Participant Name: _____________________________________________________________________,
First Middle,Last
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Participant Date of Birth: _______________________________________________________________,
Month,Day Year
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Participant Telephone Number: (),
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INSTRUCTIONS,
"• Do not fold, staple or tear the pages of this form.",
• Use a #2 PENCIL to mark your answers.,
• Make heavy black marks that fill the circle completely.,
"• If you need to change an answer, be sure to erase completely.",
"• Mark only one response for each question, unless the instructions tell you otherwise.",
• Some questions ask you to write your answer in the space provided.,
• Some questions also have additional instructions next to certain answers. These instructions,
may either ask you to skip questions that do not apply to you or ask you to provide additional,
"information. First darken the appropriate circle, then follow the instructions as directed. Unless",
"instructed otherwise, go to the next question.",
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CORRECT MARK INCORRECT MARKS,
 ,