SPIROMICS Data Collection Forms and QxQs (Current)

Code Version Title Date Form QxQ
HIQ 2.0 Home Information Questionnaire 03/12/2018 PDF icon PDF PDF icon PDF
HFA 1.0 Additional Medical History Form 02/14/2020 PDF icon PDF PDF icon PDF
AES 2.0 Adverse Events Form 01/09/2020 PDF icon PDF PDF icon PDF
ALD 2.0 Aldrete Score Form 01/06/2020 PDF icon PDF PDF icon PDF
ANT 2.0 Anthropometry Form 02/13/2018 PDF icon PDF PDF icon PDF
BIO 4.0 Biospecimen Collection Form 05/22/2018 PDF icon PDF PDF icon PDF
HFB 1.0 Blood Collection Form 12/13/2019 PDF icon PDF PDF icon PDF
BPF 3.0 Blood Pressure Form 11/05/2018 PDF icon PDF PDF icon PDF
BWR 1.0 Blood Work Results Form 01/31/2020 PDF icon PDF PDF icon PDF
BCT 2.0 Bronchoscopy Informed Consent Tracking Form 07/18/2019 PDF icon PDF PDF icon PDF
BCW 4.0 Bronchoscopy Specimen Collection Worksheet 02/04/2020 PDF icon PDF PDF icon PDF
BPW 4.0 Bronchoscopy Specimen Processing Worksheet 12/12/2019 PDF icon PDF PDF icon PDF
BIE 3.0 Bronchoscopy Substudy Inclusion/ Exclusion Criteria Form 10/11/2019 PDF icon PDF PDF icon PDF
BID 2.0 Bronchoscopy Substudy Lab ID Form 07/18/2019 PDF icon PDF PDF icon PDF
BLY 1.0 Bronchoscopy Substudy Lysate BRN ID Form 12/11/2020 PDF icon PDF PDF icon PDF
BMU 1.0 Bronchoscopy Substudy Mucin BRN ID Form 08/29/2019 PDF icon PDF PDF icon PDF
BMB 1.0 Bronchoscopy Substudy Mucin Brush BRN ID Form 08/29/2019 PDF icon PDF PDF icon PDF
BSY 1.0 Bronchoscopy Substudy Sputolysin BRN ID Form 08/29/2019 PDF icon PDF PDF icon PDF
BSL 1.0 Bronchoscopy Substudy Sputum Slide BRN ID Form 08/29/2019 PDF icon PDF PDF icon PDF
BWF 2.0 Bronchoscopy Substudy Withdrawal Form 07/18/2019 PDF icon PDF PDF icon PDF
DBS 1.0 C4R Dried Blood Spot Form 03/18/2021 PDF icon PDF PDF icon PDF
CAF 2.0 Cancer Abstraction Form- Endpoints 03/18/2021 PDF icon PDF PDF icon PDF
ESR 2.0 Cardiologist Safety Review Form- Echo 08/21/2020 PDF icon PDF PDF icon PDF
CBC 3.0 CBC Results Form 04/02/2019 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 11/12/2018 PDF icon PDF PDF icon PDF
HCT 1.0 Consent Tracking Form 06/09/2020 PDF icon PDF PDF icon PDF
CIF 3.0 Contact Information Form 01/31/2018 PDF icon PDF PDF icon PDF
CAT 2.0 COPD Assessment Test 11/03/2017 PDF icon PDF PDF icon PDF
COV 1.0 COVID-19 Questionnaire 05/28/2020 PDF icon PDF PDF icon PDF
COP 1.0 COVID-19 Questionnaire - Proxy 06/10/2020 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 2.0 Death Certificate Form 05/05/2020 PDF icon PDF PDF icon PDF
DEM 4.0 Demographic Information Form 10/23/2017 PDF icon PDF PDF icon PDF
ECF 3.0 e-Cigarette Use Assessment for Follow-Up Form 09/24/2019 PDF icon PDF PDF icon PDF
ECH 2.0 Echo Completion Form 08/07/2020 PDF icon PDF PDF icon PDF
ECA 1.0 eCigarette Use Assessment 06/11/2014 PDF icon PDF
EHA 2.0 Employment History Form for Follow-Up 12/18/2017 PDF icon PDF PDF icon PDF
ERF 2.0 Event Review Form- Endpoints 03/18/2021 PDF icon PDF PDF icon PDF
ETF 2.0 Event Tracking Form- Endpoints 01/05/2021 PDF icon PDF PDF icon PDF
EAF 2.0 Exacerbation Assessment Form 05/14/2019 PDF icon PDF PDF icon PDF
EDD 1.0 Exacerbation Daily Symptom Diary 06/05/2019 PDF icon PDF PDF icon PDF
ECT 2.0 Exacerbation Informed Consent Tracking Form 05/14/2019 PDF icon PDF PDF icon PDF
EPV 1.0 Exacerbation Phone Visit Form (Baseline) 03/03/2021 PDF icon PDF PDF icon PDF
EBI 1.0 Exacerbation Substudy Biospecimen Collection Form 09/25/2019 PDF icon PDF PDF icon PDF
EBS 1.0 Exacerbation Substudy Blood Spot PEX ID Form 03/08/2021 PDF icon PDF PDF icon PDF
EFA 1.0 Exacerbation Substudy Follow-Up Assessment Form 10/01/2019 PDF icon PDF PDF icon PDF
EIP 1.0 Exacerbation Substudy Induced Sputum Worksheet 02/12/2020 PDF icon PDF PDF icon PDF
EIW 1.0 Exacerbation Substudy Induced Sputum Worksheet 02/12/2020 PDF icon PDF PDF icon PDF
EID 2.0 Exacerbation Substudy Lab ID Form 05/14/2019 PDF icon PDF PDF icon PDF
ELY 1.0 Exacerbation Substudy Lysate PEX ID Form 08/29/2019 PDF icon PDF PDF icon PDF
EMU 1.0 Exacerbation Substudy Mucin PEX ID Form 08/29/2019 PDF icon PDF PDF icon PDF
ENS 1.0 Exacerbation Substudy Nasal Swab PEX ID Form 03/08/2021 PDF icon PDF PDF icon PDF
EPX 1.0 Exacerbation Substudy Paxgene PEX ID Form 08/29/2019 PDF icon PDF PDF icon PDF
ESS 1.0 Exacerbation Substudy Spontaneous Sputum PEX ID Form 03/18/2021 PDF icon PDF PDF icon PDF
SSW 1.0 Exacerbation Substudy Spontaneous Sputum Processing Worksheet 02/19/2020 PDF icon PDF PDF icon PDF
ESY 1.0 Exacerbation Substudy Sputolysis Slide PEX ID Form 08/29/2019 PDF icon PDF PDF icon PDF
ESL 1.0 Exacerbation Substudy Sputum Slide PEX ID Form 08/29/2019 PDF icon PDF PDF icon PDF
EWF 2.0 Exacerbation Substudy Withdrawal Form 05/14/2019 PDF icon PDF PDF icon PDF
EBC 1.0 Exhaled Breath Condensate Collection Form 06/11/2019 PDF icon PDF 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 05/19/2020 PDF icon PDF PDF icon PDF
FCT 2.0 Functional Assessment of Chronic Illness Therapy-Fatigue 03/13/2018 PDF icon PDF PDF icon PDF
HBC 1.0 Hair and Buccal Collection Form 03/05/2019 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- Endpoints 11/25/2020 PDF icon PDF PDF icon PDF
CTF 3.0 Image Acquisition Form for Follow-Up 11/12/2018 PDF icon PDF PDF icon PDF
ISP 5.0 Induced Sputum Worksheet 09/24/2019 PDF icon PDF PDF icon PDF
ISW 5.0 Induced Sputum Worksheet 09/24/2019 PDF icon PDF PDF icon PDF
IFI 2.0 Informant Interview- Endpoints 10/23/2020 PDF icon PDF PDF icon PDF
ITF 4.0 Informed Consent Tracking Form 05/28/2020 PDF icon PDF PDF icon PDF
KCC 1.0 KCCQ-12 Cardiomyopathy Questionnaire 02/13/2020 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 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
MRE 1.0 MRI Exclusion Form 12/02/2020 PDF icon PDF PDF icon PDF
MRI 1.0 MRI Pre-Completion Form 10/02/2020 PDF icon PDF PDF icon PDF
MRT 2.0 MRI Tech Completion Form 02/24/2021 PDF icon PDF PDF icon PDF
MUC 1.0 Mucin Lab ID Form 06/11/2018 PDF icon PDF PDF icon PDF
NSC 1.0 Nasal Swab Biospecimen Collection 10/03/2019 PDF icon PDF PDF icon PDF
NQT 1.0 Nutritionquest Tracking Form 04/29/2020 PDF icon PDF PDF icon PDF
NQS 1.0 Nutritonquest Questionnaire ID Form 03/05/2019 PDF icon PDF, PDF icon PDF, PDF icon PDF PDF icon PDF
OSC 1.0 Oscillometry Data Form 06/19/2019 PDF icon PDF PDF icon PDF
OSR 1.0 Oscillometry Reading Center Data Form 11/24/2020 PDF icon PDF PDF icon PDF
PAX 1.0 Paxgene Lab ID Form 05/09/2018 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 2.0 Physician Questionnaire- Endpoints 12/02/2020 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
MSR 2.0 Radiologist Safety Review Form- MRI 11/12/2020 PDF icon PDF PDF icon PDF
RSW 2.0 Reason for Study Withdrawal Form 11/08/2017 PDF icon PDF PDF icon PDF
RDB 1.0 Respiatory Disease and Smoke Exposure Questionnaire- Brief 02/06/2020 PDF icon PDF PDF icon PDF
RDF 2.0 Respiratory Disease and Smoke Exposure Questionnaire for Follow-Up 08/24/2018 PDF icon PDF PDF icon PDF
RRM 1.0 Revised Respiratory Medication Use Questionnaire 08/14/2018 PDF icon PDF PDF icon PDF
HFS 1.0 Screening Form 01/30/2020 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 4.0 Six Minute Walk Test 11/19/2018 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 6.0 Sputum Processing Worksheet 04/22/2019 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
SGR 3.0 St. George's Respiratory Questionnaire 10/24/2017 PDF icon PDF PDF icon PDF
SKF 1.0 Stool Kit ID Form 03/26/2019 PDF icon PDF PDF icon PDF
STL 1.0 Stool Sample Collection Form 12/12/2019 PDF icon PDF, PDF icon PDF PDF icon PDF
SSP 1.0 Stress Scale Phone Assessment 10/13/2020 PDF icon PDF PDF icon PDF
HFW 1.0 Study Withdrawal Form 01/21/2020 PDF icon PDF PDF icon PDF
TEA 2.0 Telephone Exacerbation Assessment Form 03/02/2021 PDF icon PDF PDF icon PDF
TEC 2.0 Temporary Exclusion Criteria Form 07/07/2020 PDF icon PDF PDF icon PDF
VSA 2.0 Veterans Specific Activity Questionnaire 12/14/2017 PDF icon PDF PDF icon PDF