Form:	Lung Reference Participant Set B v1.0

CDE ID	CDE Description
* 1063	Site Participant ID (Go To: 422)
* 422	EDRN Site ID (Go To: 423)
* 423	EDRN Protocol ID (Go To: 1219)
* 1219	Date of contact (MM/DD/YYYY): (Go To: 2655)
* 2655	Proposed study group (Go To: 1319)
	Permissible Values (value): Set B Cases: Lung cancer (CT screening) (6)
	Set B Controls: High Risk with CT nodule (8)
	Set B Controls: High risk with no nodule (9)
	Set B Controls: Other cancers (10)
* 1319	Date participant signed consent form (MM/DD/YYYY): (Go To: 1320)
* 1320	Gender (What is your gender?) (Go To: 1322)
	Permissible Values (value): Male (1)
	Female (2)
	Unknown/refused (9)
* 1322	Hispanic or Latino (Are you Hispanic or Latino?) (Go To: 1315)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
* 1315	Race (What is your race? Check all that apply.) (Go To: 1300)
	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)
	Other (95)
	Other, specify: (97) (Go To: 1294)
	Unknown/refused (99)
1294	Race (Other, specify) (Go To: 1300)
* 1300	Ever 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: 1326)
	Permissible Values (value): No (0)
	Yes (1) (Go To: 1299)
	Unknown/refused (9)
* 1299	Currently 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)
	Unknown/refused (9)
* 1298	Age quit smoking cigarettes? (How old were you when you permanently quit smoking cigarettes?) (Go To: 1297)
* 1297	Age 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)
* 1325	Average number of cigarettes smoked per day? (During the time you have smoked, on average, how many cigarettes did you smoke per day?) (Go To: 1715)
* 1715	Total number of pack years smoked. (Go To: 1326)
1326	Ever smoke cigars regularly, at least one cigar a day, for a year or more? (Have you ever smoked cigars regularly, at least one a day, for a year or more?) (Go To: 1211)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
1211	Do you now or did you ever smoke a pipe for a year or longer? (Go To: 1225)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
1225	Do you now or did you ever chew tobacco for a year or longer? (Go To: 1231)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
1231	Is there a smoker in participant´s household? (Go To: 1230)
	Permissible Values (value): No (0)
	Yes (1) (Go To: 1232)
	Unknown/refused (9)
1232	How many years was participant exposed to second hand smoke in the home? (Go To: 1229)
1229	Has participant been exposed to any of the following known lung carcinogens greater than 8 hours per week for one year? (Check all that apply.) (Go To: 1214)
	Permissible Values (value): Asbestos (1)
	Radon (2)
	Uranium (3)
	Silica (4)
	Coal dust (5)
	None (44)
	Other, specify: (97) (Go To: 1230)
1230	Exposure to known lung carcinogens (other, specify): (Go To: 1214)
1214	What is your living environment? (Go To: 1226)
	Permissible Values (value): Live in own home (1)
	Live in assisted living (2)
	Live in a nursing home (3)
	Live with child/children (4)
	Live with friends (5)
	Other, specify: (7) (Go To: 1215)
1215	What is your living environment (other, specify): (Go To: 1226)
1226	If you live at home, who else lives with you? (Go To: 1227)
1227	If you have children, do they live within an hour´s drive? (Go To: 1045)
1045	Performance status (Which of the following options would you say describes your current performance status?) (Go To: 1328)
	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)
1328	Has participant ever had at least one drink of alcohol [beer, liquor, wine, or wine coolers] per month during a twelve-month period? (Have you ever had at least one drink of alcohol [beer, liquor, wine, or wine coolers] per month during a twelve-month period?) (Go To: 1233)
	Permissible Values (value): No (0)
	Yes (1) (Go To: 1329)
	Unknown/refused (9)
1329	On average, how many glasses of wine do you drink? Count a four-ounce glass of wine as one drink. (Go To: 1330)
	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)
1330	On average, how many glasses/cans of beer do you drink? Count a twelve-ounce can as one beer. (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)
1331	On 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: 1233)
	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)
1233	If you use any illicit drugs, please specify: (Go To: 1307)
* 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: 1097)
	Permissible Values (value): No (0)
	Yes (1)
	Unknown/refused (9)
1097	Comments (do not include any participant identifiers) (Go To: End of Form)