Form:	(EXPIRED) Canary: PASS Eligibility v2.0

CDE ID	CDE Description
* 421	EDRN Participant ID (Go To: 423)
* 423	EDRN Protocol ID (Go To: 422)
* 422	EDRN Site 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: 1586)
* 1586	Presence of prostate adenocarcinoma: (Go To: End of Form)
	Permissible Values (value): Malignancy absent (1)
	Malignancy present (2)
* 975	Prostate T-Stage, Clinical (Go To: End of Form)
	Permissible Values (value): T0 (2)
	T1a (4)
	T1b (5)
	T1c (6)
	T2a (8)
	T2b (9)
	T2c (10)
	T3a (12)
	T3b (13)
	T4 (14)
	TX (15)
* 1594	Prostate N-Stage, Clinical (Go To: End of Form)
	Permissible Values (value): NX (1)
	N0 (2)
	N1 (3)
* 1694	Prostate M-Stage, Clinical : (Go To: End of Form)
	Permissible Values (value): MX (1)
	M0 (2)
	M1 (3)
	M1a (4)
	M1b (5)
	M1c (6)
* 2151	Have you received any treatment for prostate cancer? (Go To: End of Form)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
* 2148	Primary cancer treatment(s) received: (Go To: End of Form)
	Permissible Values (value): Chemotherapy (1)
	Radiation therapy (2)
	Surgery (3)
	Cryotherapy (5)
	LHRH agonists or anti-androgens hormone therapy (6)
	Other hormone therapy (e.g. testosterone patch) (7)
	Unknown/refused (9)
	Other, specify: (97)
* 2150	Primary cancer treatment(s) received: (Other, specify) (Go To: 1045)
* 1045	Performance status (Which of the following options would you say describes your current performance status?) (Go To: End of Form)
	Permissible Values (value): Fully active, able to carry on all pre-disease performance without restriction (0)
	Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (1)
	Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours (2)
	Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (3)
	Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair (4)
* 1307	Ever 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: 2621)
	Permissible Values (value): No (0)
	Yes (1) (Go To: 1341)
* 1341	Cancer type/location (Go To: 2149)
	Permissible Values (value): Bladder (1)
	Bone (2)
	Brain (3)
	Breast (4)
	Colon (6)
	Esophagus (7)
	Head & neck (mouth, nose, and throat) (8)
	Hypopharynx (27)
	Kidney (9)
	Larynx (28)
	Leukemia (11)
	Liver (10)
	Lung (12)
	Lymphoma, including Hodgkins (13)
	Nasopharynx (29)
	Oral Cavity (31)
	Oropharynx (30)
	Pancreas (15)
	Rectum (17)
	Skin (melanoma, no basal or squamous) (18)
	Stomach (19)
	Testis (24)
	Thyroid (20)
	Other, specify: (97) (Go To: 1339)
	Unknown/refused (99)
* 1339	Cancer type/location (Other, specify) (Go To: 2149)
* 2149	Has the participant been cancer-free for 5 years or more? (Other than basal/squamous cell skin cancer.) (Go To: End of Form)
	Permissible Values (value): Free from all other cancers for 5 years or more (2)
	Free from all other cancers except basal/squamous skin cancer for 5 years or more (3)
	Free from all other cancers except superficial (Ta) bladder cancer for 5 years or more (can also have had basal/squamous skin cancer) (4)
	Have had other cancer in the past 5 years (5)
	Unknown/refused (9)
* 842	Bladder T-Stage, Clinical (Go To: End of Form)
	Permissible Values (value): TX (1)
	Ta (3)
	Tis (4)
	T1 (5)
	T2 (6)
	T3 (7)
	T4 (8)
	T4a (9)
	T4b (10)
* 2621	Timing of diagnosis: (Go To: End of Form)
	Permissible Values (value): Within one year (to the day) prior to baseline visit (2)
	More than one year prior to baseline visit (3)
	Unknown (99)
* 2622	Timing of biopsy: (Go To: End of Form)
	Permissible Values (value): No 10-core biopsy (0)
	At baseline visit (1)
	Within one year (to the day) prior to baseline visit (2)
	Unknown (99)
* 2624	Date of biopsy with at least 10 cores (MM/DD/YYYY): (Go To: 1837)
* 2623	Are there a minimum of 2 biopsies, one of which is at or within 2 years prior to baseline visit? (Go To: End of Form)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown (99)
* 2625	Date of most recent biopsy (MM/DD/YYYY): (Go To: 1837)
* 1837	Date of cancer diagnosis (MM/DD/YYYY): (Go To: 1097)
1097	Comments (do not include any participant identifiers) (Go To: End of Form)
2572	Principal Investigator signature: (Go To: End of Form)