Form:Chile-US Participant Follow-up v1.1


CDE IDCDE Description
* 421EDRN Participant ID (Go To: 4556)
* 4556Date of contact (DD/MM/YYYY): (Go To: 2176)
* 2176Visit code (Go To: 423)
 
Permissible Values (value):Y1V06 (20)
 
 Y1V12 (21)
 
 Y2V06 (22)
 
 Y2V12 (23)
 
 Y3V06 (24)
 
 Y3V12 (25)
* 423EDRN Protocol ID (Go To: 422)
* 422EDRN Site ID (Go To: 929)
* 929EDRN Staff ID of the person who collected the data: (Go To: 2785)
* 2785Weight, kg: (Go To: 4030)
* 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: 1299)
 
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: 4007)
 
Permissible Values (value):No (0)
 
 Yes (1)
 
 Refused (88)
 
 Unknown (99)
* 4007Total number of months exposed to asbestos: (Go To: 1299)
* 1299Currently smoke at least one cigarette a day? (Do you currently smoke cigarettes regularly, at least one a day?) (Go To: 3060)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1325)
 
 Refused (88)
 
 Unknown (99)
* 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: 3060)
* 3060Since your last study contact, have you had any of the following symptoms? (Check all that apply) (Go To: 3056)
 
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)
* 3056Since your last study contact, have you been treated in a hospital for any of the following conditions? (Go To: 3054)
 
Permissible Values (value):Abdominal conditions (1)
 
 Heart conditions (2)
 
 Kidney conditions (3)
 
 Lung conditions (4)
 
 None (44)
 
 Refused (88)
 
 Unknown (99)
* 3054Since your last study contact, have you 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: 3057)
 
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)
* 3057Has the participant received any of the following procedures since last study contact? (Check all that apply) (Go To: 1334)
 
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: 1334)
* 1334New primary cancer [other than basal/squamous cell skin cancer] confirmed by a doctor since last routine study contact? (Have you been diagnosed with a new primary cancer [other than basal/squamous cell skin cancer] since your last routine study contact?) (Go To: 1360)
 
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: 1343)
* 1343Cancer 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)
 
 None (44)
 
 Multiple myeloma (44)
 
 Refused (88)
 
 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: 1360)
* 1360Have any of your first degree blood relatives (biological parents, siblings, children) been diagnosed with cancer [other than basal/squamous cell skin cancer] since your last routine study contact? [Not including half-siblings, step-siblings, 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: 3201)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
 
 9 (9)
 
 10 (10)
* 3201Line 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)
 
 Refused (88)
 
 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)