Data Collection Forms and QxQs

Code Version Title Date Form QxQ
HIQ 2.0 Home Information Questionnaire 03/12/2018 PDF icon PDF PDF icon PDF
AES 1.0 Adverse Events Form 06/10/2014 PDF icon PDF
AES 2.0 Adverse Events Form 10/25/2017 PDF icon PDF PDF icon PDF
ANT 1.0 Anthropometry Form 10/26/2010 PDF icon PDF PDF icon PDF
ANT 2.0 Anthropometry Form 02/13/2018 PDF icon PDF PDF icon PDF
BEQ 1.0 Baseline Exacerbation History 11/02/2010 PDF icon PDF PDF icon PDF
BMH 2.0 Baseline Medical History 07/06/2011 PDF icon PDF PDF icon PDF
BIO 2.0 Biospecimen Collection Form 01/25/2011 PDF icon PDF PDF icon PDF
BIO 4.0 Biospecimen Collection Form 05/22/2018 PDF icon PDF PDF icon PDF
BPF 1.0 Blood Pressure Form 10/26/2010 PDF icon PDF PDF icon PDF
BPF 2.0 Blood Pressure Form 09/28/2017 PDF icon PDF PDF icon PDF
BIS 1.0 Bronchitis Index Scoring 03/02/2012 PDF icon PDF
BIE 1.0 Bronchoscopy Inclusion/Exclusion Form 03/06/2012 PDF icon PDF
BCT 1.0 Bronchoscopy Informed Consent Tracking 12/20/2011 PDF icon PDF
BID 1.0 Bronchoscopy Lab ID Form 08/26/2013 PDF icon PDF
BCW 1.0 Bronchoscopy Specimen Collection Worksheet 02/22/2012 PDF icon PDF
BPW 3.0 Bronchoscopy Specimen Collection Worksheet 06/10/2014 PDF icon PDF
BSD 1.0 Bronchoscopy Sputum Lab ID Form 08/26/2013 PDF icon PDF
BSW 2.0 Bronchoscopy Sputum Processing Worksheet 03/06/2012 PDF icon PDF
BWF 1.0 Bronchoscopy Substudy Withdrawal 12/20/2011 PDF icon PDF
CAF 1.0 Cancer Abstraction Form 02/16/2015 PDF icon PDF
CBC 1.1 CBC Results Form 02/16/2011 PDF icon PDF
CBC 3.0 CBC Results Form 05/31/2018 PDF icon PDF PDF icon PDF
CCL 1.0 Clinical Center Itinerary 10/26/2010 PDF icon PDF PDF icon PDF
CSF 1.0 Clinically Significant Findings Form 05/31/2018 PDF icon PDF PDF icon PDF
CIF 1.0 Contact Information Form 09/21/2011 PDF icon PDF
CIF 3.0 Contact Information Form 01/31/2018 PDF icon PDF PDF icon PDF
CEA 1.0 Coordinator Exacerbation Assessment (Wave 1) 05/27/2014 PDF icon PDF
CAT 2.0 COPD Assessment Test 11/03/2017 PDF icon PDF PDF icon PDF
CTA 2.0 CT Image Acquisition and Transmittal Form 02/17/2012 PDF icon PDF PDF icon PDF
DCF 1.0 Death Certificate Form 12/15/2014 PDF icon PDF
DEM 4.0 Demographic Information Form 10/23/2017 PDF icon PDF PDF icon PDF
DEM 3.0 Demographic Information Form 07/08/2011 PDF icon PDF PDF icon PDF
DMF 1.0 Diabetes Abstraction Form 02/19/2015 PDF icon PDF
ECF 2.0 e-Cigarette Use Assessment for Follow-Up Form 03/08/2018 PDF icon PDF PDF icon PDF
ECA 1.0 eCigarette Use Assessment 06/11/2014 PDF icon PDF
EHF 2.1 Employment History Form 05/08/2011 PDF icon PDF PDF icon PDF
EHA 1.0 Employment History Form - Annual Visits 09/21/2011 PDF icon PDF
EHA 2.0 Employment History Form for Follow-Up 12/18/2017 PDF icon PDF PDF icon PDF
ETF 1.0 Event Tracking Form 12/15/2014 PDF icon PDF
EAF 1.0 Exacerbation Assessment 05/27/2014 PDF icon PDF
ERF 1.0 Exacerbation Resolution 08/19/2013 PDF icon PDF
FEE 1.0 Follow-Up Exacerbation Extended Questionnaire 05/23/2018 PDF icon PDF PDF icon PDF
FEQ 1.0 Follow-Up Exacerbation Questionnaire 03/06/2018 PDF icon PDF PDF icon PDF
FUQ 3.0 Follow-Up Phone Questionnaire 02/27/2018 PDF icon PDF PDF icon PDF
FUQ 1.0 Follow-up Questionnaire 11/02/2010 PDF icon PDF
FCT 2.0 Functional Assessment of Chronic Illness Therapy-Fatigue 03/13/2018 PDF icon PDF PDF icon PDF
HGS 1.0 Hand Grip Strength Form 09/20/2017 PDF icon PDF PDF icon PDF
HDS 2.0 Hospital Anxiety and Depression Scale 10/09/2017 PDF icon PDF PDF icon PDF
HRA 2.0 Hospital Record Abstraction Form 10/23/2015 PDF icon PDF
HEF 1.0 Hospitalizations and Exacerbations 09/21/2011 PDF icon PDF
CTF 2.0 Image Acquisition Form for Follow-Up 12/22/2017 PDF icon PDF PDF icon PDF
IEC 3.0 Inclusion/Exclusion Criteria Form 08/03/2011 PDF icon PDF PDF icon PDF
ISP 3.0 Induced Sputum Worksheet 03/23/2018 PDF icon PDF PDF icon PDF
ISW 3.0 Induced Sputum Worksheet 03/23/2018 PDF icon PDF PDF icon PDF
IFI 1.0 Informant Interview 11/10/2010 PDF icon PDF
ICT 2.0 Informed Consent Tracking 07/26/2011 PDF icon PDF
ITF 3.0 Informed Consent Tracking Form 06/04/2018 PDF icon PDF PDF icon PDF
LAB 1.0 Lab ID Form 10/26/2010 PDF icon PDF PDF icon PDF
LAB 2.0 Lab ID Form 12/13/2017 PDF icon PDF PDF icon PDF
LYS 1.0 Lysate Lab ID Form 05/10/2018 PDF icon PDF PDF icon PDF
MHF 1.0 Medical History Form for Follow-Up 09/21/2011 PDF icon PDF
MHF 3.0 Medical History Form for Follow-Up 01/09/2018 PDF icon PDF PDF icon PDF
MRC 2.0 Modified Medical Research Council Dyspnea Scale 10/09/2017 PDF icon PDF PDF icon PDF
MRC 1.0 Modified MRC Dyspnea Scale 10/26/2010 PDF icon PDF PDF icon PDF
MCF 1.0 Monthly Contact 06/17/2013 PDF icon PDF
MUC 1.0 Mucin Lab ID Form 06/11/2018 PDF icon PDF PDF icon PDF
MIF 1.0 Myocardial Infarction Abstraction Form 02/12/2015 PDF icon PDF
PAX 1.0 Paxgene Lab ID Form 05/09/2018 PDF icon PDF PDF icon PDF
PID 2.0 Personal Identifiers Form 11/09/2010 PDF icon PDF PDF icon PDF
PID 3.0 Personal Identifiers Form 01/09/2018 PDF icon PDF PDF icon PDF
PTA 1.0 Phantom Acquisition and Transmittal Form 10/26/2010 PDF icon PDF
PLI 2.0 Phantom Lab ID Form 06/13/2018 PDF icon PDF PDF icon PDF
PQE 1.0 Physician Questionnaire 01/21/2015 PDF icon PDF
PSQ 1.1 Pittsburgh Sleep Quality Index 07/12/2011 PDF icon PDF PDF icon PDF
PRH 1.0 Pollution and Residential History Form 10/26/2010 PDF icon PDF PDF icon PDF
PFT 1.0 Pulmonary Function Eligibility 10/26/2010 PDF icon PDF PDF icon PDF
PFE 1.0 Pulmonary Function Eligibility Form 11/15/2017 PDF icon PDF PDF icon PDF
MCQ 2.0 Questionnaire for Ease and Cough and Sputum Clearance 10/09/2017 PDF icon PDF PDF icon PDF
RSW 2.0 Reason for Study Withdrawal Form 11/08/2017 PDF icon PDF PDF icon PDF
RDS 3.0 Respiratory Disease and Smoke Exposure Questionnaire 08/02/2011 PDF icon PDF PDF icon PDF
RDF 1.0 Respiratory Disease and Smoke Exposure Questionnaire for Follow-Up 09/21/2011 PDF icon PDF
RDF 2.0 Respiratory Disease and Smoke Exposure Questionnaire for Follow-Up 02/13/2018 PDF icon PDF PDF icon PDF
RMU 1.0 Respiratory Medication Use Questionnaire 10/26/2010 PDF icon PDF PDF icon PDF
RTF 1.0 Review Tracking Form 01/20/2016 PDF icon PDF
RRM 1.0 Revised Respiratory Medication Use Questionnaire 11/15/2017 PDF icon PDF PDF icon PDF
SFH 3.0 SF12 Health Survey 11/07/2017 PDF icon PDF PDF icon PDF
SPB 1.0 Short Physical Performance Battery 02/05/2018 PDF icon PDF PDF icon PDF
SMW 1.0 Six Minute Walk Test 10/26/2010 PDF icon PDF PDF icon PDF
SMW 3.0 Six Minute Walk Test 01/17/2018 PDF icon PDF PDF icon PDF
SDF 1.0 Spirometry Data Form 11/02/2010 PDF icon PDF PDF icon PDF
SDF 2.0 Spirometry Data Form 10/09/2017 PDF icon PDF PDF icon PDF
SLY 1.0 Sputolysin Lab ID Form 06/14/2018 PDF icon PDF PDF icon PDF
SPW 2.0 Sputum Processing Worksheet 09/12/2011 PDF icon PDF PDF icon PDF
SPW 5.0 Sputum Processing Worksheet 06/05/2018 PDF icon PDF PDF icon PDF
SPU 2.0 Sputum Slide Form 02/01/2018 PDF icon PDF PDF icon PDF
SLI 1.0 Sputum Slide Lab ID Form 05/10/2018 PDF icon PDF PDF icon PDF
ISP 1.0 Sputum Worksheet for post albuterol FEV1 < 1 liter 10/26/2010 PDF icon PDF PDF icon PDF
ISW 1.1 Sputum Worksheet for post albuterol FEV1 > 1 liter 09/19/2011 PDF icon PDF PDF icon PDF
SGR 3.0 St. George's Respiratory Questionnaire 10/24/2017 PDF icon PDF PDF icon PDF
STR 1.0 Stroke Abstraction Form 06/25/2015 PDF icon PDF
RSW 1.0 Study Withdrawal Form 10/20/2010 PDF icon PDF PDF icon PDF
VTD 1.0 Venous Thromboembolic Disease Abstraction Form 02/12/2015 PDF icon PDF
VSA 2.0 Veterans Specific Activity Questionnaire 12/14/2017 PDF icon PDF PDF icon PDF