Version Date: 10/99   Expiration Date: 7/05,Form Approved OMB No.: 0925-0407
Participant ID Number,
"Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial",
FLEXIBLE SIGMOIDOSCOPY SCREENING EXAMINATION (FSG2),
"DO NOT FOLD, STAPLE, OR TEAR THIS FORM.  USE A NO. 2 PENCIL TO COMPLETE THIS FORM.",
1. Date of Examination: ___________________________________________,
Month Day,Year
2. Screening Center: ___ ___,
3. Satellite Center: ___ ___,
4. Study Year:,
〇 T0,
〇 T5,
5. Visit Number:,
〇 One,
〇 Two,
〇 Three,
6. Reason for Repeat Visit:,
_______________________________,
_______________________________,
_______________________________,
_______________________________,
FOR OFFICE USE ONLY,
7. Form Processing (MARK RESPONSES AS STEPS ARE COMPLETED),
〇 Form Receipted into SMS,
〇 Manual Review Completed,
Data Entry of Non-Scannable Items:,
〇 Completed OR,
〇 None Required,