Form:Chile-US Participant Baseline v1.1


CDE IDCDE Description
* 421EDRN Participant ID (Go To: 2176)
* 2176Visit code (Go To: 423)
 
Permissible Values (value):BLN1 (1)
 
 BLN2 (2)
 
 BLN3 (3)
 
 BLN4 (4)
* 423EDRN Protocol ID (Go To: 422)
* 422EDRN Site ID (Go To: 929)
* 929EDRN Staff ID of the person who collected the data: (Go To: 4556)
* 4556Date of contact (DD/MM/YYYY): (Go To: 2788)
* 2788Age at selection: (Go To: 2787)
* 2787Height, cm: (Go To: 2785)
* 2785Weight, kg: (Go To: 1320)
* 1320Gender (What is your gender?) (Go To: 1322)
 
Permissible Values (value):Male (1)
 
 Female (2)
 
 Refused (88)
 
 Unknown (99)
* 1322Hispanic or Latino (Are you Hispanic or Latino?) (Go To: 1315)
 
Permissible Values (value):No (0)
 
 Yes (1)
 
 Refused (88)
 
 Unknown (99)
* 1315Race (What is your race? Check all that apply.) (Go To: 4001)
 
Permissible Values (value):White (1)
 
 Black or African-American (2)
 
 American Indian or Alaska Native (3)
 
 Asian (4)
 
 Native Hawaiian or other Pacific Islander (7)
 
 Refused (88)
 
 Other, specify: (97) (Go To: 1294)
 
 Unknown (99)
* 1294Race (Other, specify) (Go To: 4001)
* 4001Date work began: (MM/YYYY) (Go To: 4000)
* 4000Was the participant monitored by MSCChC? (Go To: 4003)
 
Permissible Values (value):No (0) (Go To: End of Form)
 
 Yes (1)
 
 Refused (88) (Go To: End of Form)
 
 Unknown (99) (Go To: End of Form)
* 4003Was the participant covered by workplace insurance? (Go To: 4030)
 
Permissible Values (value):No (0) (Go To: End of Form)
 
 Yes (1)
 
 Refused (88) (Go To: End of Form)
 
 Unknown (99) (Go To: End of Form)
* 4030Level 1 work station name and asbestos exposure (fibers/cm3) (Check all that apply): (Go To: 4035)
 
Permissible Values (value):Stripper command P3, 0.08 (1)
 
 Peel command P3, 0.08 (2)
 
 Inverter command P3, 0.06 (3)
 
 Emery wet recovery P3, 0.08 (4)
 
 Spinner, 0.06 (5)
 
 Machinist P2, 0.09 (6)
 
 Bridge crane operator cabin, 0.08 (7)
 
 Peel operator command P5, 0.05 (8)
 
 Gutter court operator, 0.06 (9)
 
 Mixer molding operator, 0.09 (10)
 
 Release tubes operator, 0.06 (11)
 
 Versatile lathe operator, 0.08 (12)
 
 Refused (88) (Go To: 4031)
 
 Not applicable (98) (Go To: 4031)
 
 Unknown (99) (Go To: 4031)
* 4035Number of months exposed to asbestos at level 1: (Go To: 4031)
* 4031Level 2 work station name and asbestos exposure (fibers/cm3) (Check all that apply): (Go To: 4036)
 
Permissible Values (value):Plates Warehouse, 0.1 (1)
 
 Tubes Warehouse, 0.14 (2)
 
 Central to punch cuts, 0.15 (3)
 
 Central grinding, 0.16 (4)
 
 Stripper command P4, 0.1 (5)
 
 Peel command P4, 0.12 (6)
 
 Peel command P5, 0.17 (7)
 
 Inverter command P4, 0.16 (8)
 
 Quality control tubes termination, 0.13 (9)
 
 Cutter Circular Saw (molded), 0.14 (10)
 
 Tiles Emery (polisher), 0.17 (11)
 
 Machinist P3, 0.14 (12)
 
 Machinist P4, 0.16 (13)
 
 Mixer deposits, 0.11 (14)
 
 Mixer P3-P4, 0.12 (15)
 
 Mixer P5, 0.18 (16)
 
 Mixer T5, 0.18 (17)
 
 Wiggler P2, 0.11 (18)
 
 Input line paintings operator, 0.17 (19)
 
 Punching operator, 0.16 (20)
 
 Output line paintings operator, 0.12 (21)
 
 Termination tubes operator, 0.18 (22)
 
 Turning tubes operator, 0.1 (23)
 
 Weighing and bagging operator, 0.1 (24)
 
 Refused (88) (Go To: 4032)
 
 Not applicable (98) (Go To: 4032)
 
 Unknown (99) (Go To: 4032)
* 4036Number of months exposed to asbestos at level 2: (Go To: 4032)
* 4032Level 3 work station name and asbestos exposure (fibers/cm3) (Check all that apply): (Go To: 4037)
 
Permissible Values (value):Mill operator , 0.15 (1)
 
 Mill operator (tubes) T5, 0.17 (2)
 
 Stripper P2, 0.22 (3)
 
 Peeler P2, 0.24 (4)
 
 Roller, 0.27 (5)
 
 Machinist P5 (molded), 0.25 (6)
 
 Machinist T5, 0.26 (7)
 
 Mixer P2, 0.22 (8)
 
 Mill operator P3, 0.28 (9)
 
 Sander operator planters, 0.25 (10)
 
 Operator termination paintings online, 0.21 (11)
 
 Mill operator P4, 0.23 (12)
 
 Mill operator , 0.22 (13)
 
 Refused (88) (Go To: 4033)
 
 Not applicable (98) (Go To: 4033)
 
 Unknown (99) (Go To: 4033)
* 4037Number of months exposed to asbestos at level 3: (Go To: 4033)
* 4033Level 4 work station name and asbestos exposure (fibers/cm3) (Check all that apply): (Go To: 4038)
 
Permissible Values (value):Unions Lathe operator, 0.42 (1)
 
 Emery /Polisher, 0.42 (2)
 
 HMS Lathe operator, 0.31 (3)
 
 Refused (88) (Go To: 4034)
 
 Not applicable (98) (Go To: 4034)
 
 Unknown (99) (Go To: 4034)
* 4038Number of months exposed to asbestos at level 4: (Go To: 4034)
* 4034Level 5 work station name and asbestos exposure (fibers/cm3) (Check all that apply): (Go To: 4039)
 
Permissible Values (value):Industrial Iron, 0.63 (1)
 
 Machinist machine deposits, 0.52 (2)
 
 Mixing machine deposits, 0.57 (3)
 
 Operator termination deposits, 0.55 (4)
 
 Sacks cellar operator, 0.5 (5)
 
 Termination laundries A operator, 1.21 (6)
 
 Refused (88) (Go To: 4040)
 
 Not applicable (98) (Go To: 4040)
 
 Unknown (99) (Go To: 4040)
* 4039Number of months exposed to asbestos at level 5: (Go To: 4040)
* 4040Did the participant work at a work station other than those already mentioned? (Go To: 1300)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 4041)
 
 Refused (88)
 
 Unknown (99)
* 4041Work station location name, other (Go To: 4008)
* 4008Does the occupation expose the worker to asbestos? (Go To: 1300)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 4007)
 
 Refused (88)
 
 Unknown (99)
* 4007Total number of months exposed to asbestos: (Go To: 1300)
* 1300Ever smoke cigarettes regularly, at least one a day for a year or more? (Did you ever smoke cigarettes regularly, at least one a day for a year or more?) (Go To: 3059)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1299)
 
 Refused (88)
 
 Unknown (99)
* 1299Currently smoke at least one cigarette a day? (Do you currently smoke cigarettes regularly, at least one a day?) (Go To: 1297)
 
Permissible Values (value):No (0) (Go To: 1298)
 
 Yes (1)
 
 Refused (88)
 
 Unknown (99)
* 1298Age quit smoking cigarettes? (How old were you when you permanently quit smoking cigarettes?) (Go To: 1297)
* 1297Age first began smoking cigarettes regularly, at least one a day? (How old were you when you began smoking cigarettes regularly, at least one a day?) (Go To: 1325)
* 1325Average number of cigarettes smoked per day? (During the time you have smoked, on average, how many cigarettes did you smoke per day?) (Go To: 1301)
* 1301Total number of years smoked? (How many years total have you smoked?) (Go To: 3059)
* 3059Do you currently have any of the following symptoms? (Check all that apply) (Go To: 3055)
 
Permissible Values (value):Abdominal distention (1)
 
 Abdominal pain (2)
 
 Angina (chest pains) (3)
 
 Cough (4)
 
 Shortness of breath (5)
 
 None (44)
 
 Refused (88)
 
 Unknown (99)
* 3055Have you ever been treated in a hospital for any of the following conditions? (Go To: 3053)
 
Permissible Values (value):Abdominal conditions (1)
 
 Heart conditions (2)
 
 Kidney conditions (3)
 
 Lung conditions (4)
 
 None (44)
 
 Refused (88)
 
 Unknown (99)
* 3053Have you ever been diagnosed by a doctor with any of the following conditions? (Check all that apply) (Go To: 3061)
 
Permissible Values (value):Angina (chest pains) (2)
 
 Arthritis or osteoporosis (thinning of bones) (3)
 
 Asbestosis (4)
 
 Asthma (5)
 
 Chronic bronchitis or emphysema (7)
 
 Dermatitis or eczema (10)
 
 Diabetes (11)
 
 Epilepsy (spells, fits, or seizures) (12)
 
 Gallstones or gall bladder disease (15)
 
 Glaucoma (16)
 
 Gout (18)
 
 Heart attack (19)
 
 Heart failure (20)
 
 Heart murmur (21)
 
 High blood pressure (hypertension) (23)
 
 Hives, hay fever, other allergies (26)
 
 Intestinal problems, for example colitis or diverticulosis (28)
 
 Kidney problems (nephritis, kidney infection, kidney stones, kidney failure) (30)
 
 Liver disease, yellow jaundice, hepatitis, cirrhosis (31)
 
 Men only: Problems of the prostate (infection, enlargement) (32)
 
 Migraine headaches (33)
 
 Nervous or emotional disorder (34)
 
 Pneumonia (37)
 
 Psoriasis (38)
 
 Serious chest injury (39)
 
 Stroke (40)
 
 Thyroid trouble (over active, under active, goiter) (41)
 
 Tuberculosis (TB) (42)
 
 Ulcers of the stomach or duodenum (43)
 
 Women only: Problems with breast (45)
 
 Women only: Problems with female organs (46)
 
 None (44)
 
 Other, specify: (97) (Go To: 3120)
 
 Refused (88)
 
 Unknown (99)
* 3120Diagnosed conditions (Other, specify): (Go To: 3061)
* 3061Currently taking any medications for any of the following conditions? (Check all that apply) (Go To: 4027)
 
Permissible Values (value):Abdominal conditions (1)
 
 Heart conditions (2)
 
 Kidney conditions (3)
 
 Lung conditions (4)
 
 None (44)
 
 Refused (88)
 
 Unknown (99)
* 4027In the past year, how often have you used aspirin? (Go To: 4028)
 
Permissible Values (value):Not at all (0)
 
 Less than 1 time/week (1)
 
 1 time/week (2)
 
 2-3 times/week (3)
 
 4-6 times/week (4)
 
 7 or more times/week (5)
 
 Refused (88)
 
 Unknown (99)
* 4028In the past year, how often have you used non-aspirin anti-inflammatory pain medicines (NSAIDS)? (Go To: 3058)
 
Permissible Values (value):Not at all (0)
 
 Less than 1 time/week (1)
 
 1 time/week (2)
 
 2-3 times/week (3)
 
 4-6 times/week (4)
 
 7 or more times/week (5)
 
 Refused (88)
 
 Unknown (99)
* 3058Has the participant received any of the following procedures prior to the time of consent? (Check all that apply) (Go To: 1307)
 
Permissible Values (value):Biopsy (1)
 
 Lapraroscopy (2)
 
 Lavage (3)
 
 Paracentesis (4)
 
 Thoracentesis (5)
 
 Thoracotomy (6)
 
 None (44)
 
 Refused (88)
 
 Other, specify: (97) (Go To: 3121)
 
 Unknown (99)
* 3121Procedures received (Other, specify): (Go To: 1307)
* 1307Ever had cancer [other than basal/squamous cell skin cancer] confirmed by a doctor? (Have you ever had cancer [other than basal/squamous cell skin cancer] confirmed by a doctor?) (Go To: 1380)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3142)
 
 Refused (88)
 
 Unknown (99)
* 3142Number of cancers to record: (Go To: 2159)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
 
 9 (9)
 
 10 (10)
* 2159Specimen line number or identifier (system-generated): (Go To: 1341)
* 1341Cancer type/location (Go To: 1302)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Uterus (21)
 
 Endometrium (22)
 
 Testis (24)
 
 Vagina (26)
 
 Gall bladder (40)
 
 Mesothelioma (42) (Go To: End of Form)
 
 Multiple myeloma (44)
 
 Refused (88) (Go To: 3158)
 
 Other (95)
 
 Unknown (99) (Go To: 3158)
* 1302Age at diagnosis (Go To: 2148)
* 2148Primary cancer treatment(s) received: (Go To: 3158)
 
Permissible Values (value):Chemotherapy (1)
 
 Radiation therapy (2)
 
 Surgery (3)
 
 Hormone therapy (4)
 
 None (44)
 
 Refused (88)
 
 Other (95)
 
 Unknown (99)
   3158Loop-specific comments: (Go To: 1380)
* 1380Number of living and deceased first-degree blood brothers: (How many living and deceased blood-related brothers do you have? [Not including adopted, foster, half-brothers or step-brothers] (Go To: 1381)
* 1381Number of living and deceased first-degree blood sisters: (How many living and deceased blood-related sisters do you have? [Not including adopted, foster, half-sisters or step-sisters] (Go To: 1378)
* 1378Number of living and deceased blood-related sons: (How many living and deceased blood-related sons do you have? [Not including adopted, foster, or step-sons] (Go To: 1379)
* 1379Number of living and deceased blood-related daughters: (How many living and deceased blood-related daughters do you have? [Not including adopted, foster, or step-daughters] (Go To: 1349)
* 1349Have any of the participant´s living and deceased first degree blood relatives been diagnosed with cancer [other than basal/squamous cell skin cancer]? (Have any of your living and deceased first degree blood relatives (biological parents, siblings, children) been diagnosed with cancer [other than basal/squamous cell skin cancer]? [Not including half-siblings, step-siblings, step-parents, or step-children]. (Go To: 1097)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3143)
 
 Refused (88)
 
 Unknown (99)
* 3143Number of relative´s cancers to record: (Go To: 3150)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
 
 9 (9)
 
 10 (10)
* 3150Specimen line number or identifier 2 (system generated): (Go To: 1351)
* 1351Relative type (mother, brother, etc) (Go To: 1311)
 
Permissible Values (value):Brother (1)
 
 Sister (2)
 
 Son (3)
 
 Daughter (4)
 
 Father (5)
 
 Mother (6)
 
 Unknown (99)
* 1311First primary cancer: (Go To: 1430)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Uterus (21)
 
 Endometrium (22)
 
 Testis (24)
 
 Vagina (26)
 
 Gall bladder (40)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Refused (88)
 
 Other (95)
 
 Unknown (99) (Go To: 3163)
* 1430Relative´s age when diagnosed (Go To: 1317)
* 1317Subsequent primary cancer(s): (Go To: 3163)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Uterus (21)
 
 Endometrium (22)
 
 Testis (24)
 
 Vagina (26)
 
 Gall bladder (40)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Refused (88)
 
 Other (95)
 
 Unknown (99)
 
 None (444)
   3163Loop-specific comments 2: (Go To: 1097)
   1097Comments (do not include any participant identifiers) (Go To: End of Form)