| CDE ID | CDE Description | | * 2777 | Site participant ID (Go To: 422) |
| * 422 | EDRN Site ID (Go To: 423) |
| * 423 | EDRN Protocol ID (Go To: 929) |
| * 929 | EDRN Staff ID of the person who collected the data: (Go To: 1219) |
| * 1219 | Date of contact (MM/DD/YYYY): (Go To: 3406) |
| * 3406 | Date of birth (MM/YYYY): (Go To: 1320) |
| * 1320 | Gender (What is your gender?) (Go To: 1322) |
| | | Permissible Values (value): | Female (2) |
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| * 1322 | Hispanic or Latino (Are you Hispanic or Latino?) (Go To: 1315) |
| | | Permissible Values (value): | No (0) |
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| * 1315 | Race (What is your race? Check all that apply.) (Go To: 2778) |
| | | Permissible Values (value): | White (1) |
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| | | | Black or African-American (2) |
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| | | | American Indian or Alaska Native (3) |
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| | | | Native Hawaiian or other Pacific Islander (7) |
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| | | | Other, specify: (97) (Go To: 1294) |
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| * 1294 | Race (Other, specify) (Go To: 2778) |
| * 2778 | Smoking status: (Go To: 1097) |
| | | Permissible Values (value): | Never (1) |
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| 1097 | Comments (do not include any participant identifiers) (Go To: End of Form) |