Form:GLNE 007 One Year Contact v9.0


CDE IDCDE Description
* 421EDRN Participant ID (Go To: 423)
* 423EDRN Protocol ID (Go To: 422)
* 422EDRN Site ID (Go To: 929)
* 929EDRN Staff ID of the person who collected the data: (Go To: 1219)
* 1219Date of contact (MM/DD/YYYY): (Go To: 3685)
* 3685Source of information collection (Go To: 3592)
 
Permissible Values (value):Patient self-report (1)
 
 Electronic medical record (4)
 
 In-person visit (5)
 
 Telephone communication (6)
 
 Email (7)
 
 Other (95)
 
 Unknown (99)
* 3592Procedure performed? (Go To: 4645)
 
Permissible Values (value):No (0)
 
 Yes (1)
 
 Refused (88)
 
 Unknown (99)
* 4645Were imaging procedures performed? (Go To: 3028)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3144)
 
 Unknown (99)
* 3144Number of loops: (Go To: 3201)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
* 3201Line number or identifier 2 (system-generated): (Go To: 4963)
* 4963Colorectal scan or procedure type (Go To: 3223)
 
Permissible Values (value):CT scan (2)
 
 MRI (4)
 
 PET scan (7)
 
 Flex sig (8)
 
 CEA (9)
 
 Other, specify: (97) (Go To: 4965)
 
 Unknown (99)
* 4965Colorectal scan or procedure type (other, specify) (Go To: 3223)
* 3223Date of procedure (MM/DD/YYYY): (Go To: 4963)
   4964Colorectal scan or procedure findings (Go To: 3272)
   3272Loop-specific comments 5: (Go To: 3028)
* 3028Diagnosed with study-related cancer?: (Go To: 4223)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3168)
 
 Refused (88)
 
 Unknown (99)
* 3168Cancer status: (Go To: 4223)
 
Permissible Values (value):Cancer free (1)
 
 Cancer remains (2)
 
 Cancer progressed (3)
 
 Cancer recurred (4) (Go To: 1221)
 
 Original tumor still present (6)
 
 Refused (88)
 
 Unknown (99)
* 1221Recurrence date (MM/YYYY): (Go To: 1277)
* 1277Time to local recurrence (TTLR): (Go To: 4223)
* 4223Weight (value): (Go To: 4224)
* 4224Weight (unit): (Go To: 2190)
 
Permissible Values (value):kg (kilograms) (1)
 
 lbs (pounds) (2)
* 2190Have your smoking habits changed since your last routine study contact? (Go To: 2196)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 2778)
 
 Refused (88)
 
 Unknown (99)
* 2778Smoking status: (Go To: 2196)
 
Permissible Values (value):Never (1)
 
 Former (2) (Go To: 1298)
 
 Current (3)
 
 Refused (88)
 
 Unknown (99) (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: 2196)
 
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: 1325)
 
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: 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: 2196)
* 1715Total number of pack years smoked. (Go To: 2196)
* 2196Has your alcohol use changed since your last routine study contact? (Go To: 1334)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1330)
 
 Refused (88)
 
 Unknown (99)
* 1330On average, how many glasses/cans of beer do you drink? Count a twelve-ounce can as one beer. (Go To: 1329)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
 
 Refused (88)
 
 Unknown (99)
* 1329On average, how many glasses of wine do you drink? Count a four-ounce glass of wine as one drink. (Go To: 1331)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
 
 Refused (88)
 
 Unknown (99)
* 1331On average, how many shots of hard liquor or mixed drinks do you drink? Count one shot (1 1/2 ounces) or one mixed drink as one drink. (Go To: 1334)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
 
 Refused (88)
 
 Unknown (99)
* 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: 1333)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Endometrium (22)
 
 Esophagus (7)
 
 Gall bladder (40)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Leukemia (11)
 
 Liver (10)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Testis (24)
 
 Thyroid (20)
 
 Uterus (21)
 
 Vagina (26)
 
 Other (95)
 
 Refused (88)
 
 Unknown (99)
* 1333Date of diagnosis (MM/YYYY): (Go To: 1302)
* 1302Age at diagnosis (Go To: 1357)
* 1357Tumor laterality (Go To: 2148)
 
Permissible Values (value):Right (1)
 
 Left (2)
 
 Both (3)
 
 N/A (8)
 
 Refused (88)
 
 Unknown (99)
* 2148Primary cancer treatment(s) received: (Go To: 4669)
 
Permissible Values (value):Chemotherapy (1) (Go To: 1260)
 
 Radiation therapy (2) (Go To: 1263)
 
 Surgery (3) (Go To: 3014)
 
 Hormone therapy (4)
 
 None (44)
 
 Refused (88)
 
 Other (95)
 
 Unknown (99)
* 3014Date of most recent cancer-related surgery (MM/YYYY): (Go To: 4669)
* 1263Radiation therapy end date: (MM/YYYY): (Go To: 4669)
* 1260Chemotherapy end date (MM/YYYY): (Go To: 4669)
* 4669Diagnosis code, ICD-9 (Go To: 1338)
* 1338Histologic confirmation? (Go To: 1358)
 
Permissible Values (value):No (0)
 
 Yes (1)
* 1358Chart Abstraction? (Go To: 3158)
 
Permissible Values (value):No (0)
 
 Yes (1)
   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: 1320)
 
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: 1361)
* 1361Relative 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)
 
 Endometrium (22)
 
 Esophagus (7)
 
 Gall bladder (40)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Leukemia (11)
 
 Liver (10)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Testis (24)
 
 Thyroid (20)
 
 Uterus (21)
 
 Vagina (26)
 
 Other (95)
 
 Refused (88)
 
 Unknown (99)
* 1430Relative´s age when diagnosed (Go To: 1317)
* 1317Subsequent primary cancer(s): (Go To: 3163)
 
Permissible Values (value):None (0)
 
 Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Endometrium (22)
 
 Esophagus (7)
 
 Fallopian tube (45)
 
 Gall bladder (40)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Leukemia (11)
 
 Liver (10)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Ovary (14)
 
 Pancreas (15)
 
 Primary peritoneal cancer (46)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Testis (24)
 
 Thyroid (20)
 
 Uterus (21)
 
 Vagina (26)
 
 Other (95)
 
 Refused (88)
 
 Unknown (99)
   3163Loop-specific comments 2: (Go To: 1320)
* 1320Gender (What is your gender?) (Go To: 1097)
 
Permissible Values (value):Male (1)
 
 Female (2) (Go To: 2982)
 
 Refused (88)
 
 Unknown (99)
* 2982Has your menstrual status changed since your last routine study contact? (Go To: 1097)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1362)
 
 Refused (88)
 
 N/A (98)
 
 Unknown (99)
* 1362Since your last routine study contact, have your menstrual periods stopped due to natural menopause, hysterectomy, the removal of both ovaries, or radiation or chemotherapy treatment? (Go To: 1097)
 
Permissible Values (value):No (0)
 
 Yes (1)
 
 Unknown/refused (9)
 
 Refused (88)
 
 Unknown (99)
   1097Comments (do not include any participant identifiers) (Go To: End of Form)