PROTOCOL SPECIFIC MATERIALS
PROTOCOL 6654 Data Forms
Decision Logs:
 
NLST Decision Log,  01/04/2010  
NLST Decision Log, 11/03/2009  
NLST Decision Log, 08/07/2009  
NLST Decision Log, 01/07/2009  
NLST Decision Log, 12/11/2008  
NLST Decision Log, 08/26/2008
 
NLST Decision Log, 03/10/2008
 
NLST Decision Log, 09/26/2005
 
NLST Decision Log, 07/27/2005
 
NLST Decision Log, 01/25/2005 
 
NLST Decision Log, 09/14/2004  
 
 
 
Form Revisions Notice (FRN):
 
03/10/2008
FRN:F2   
10/30/2006
06/17/2004 
07/31/2003
03/12/2003
01/02/2003
10/29/2002
09/27/2010
 
 
Case Report Form Set:
 
 
 
 
DATA FORMS:
Instructions
 
 
Registration/Randomization:
 
Pre-Registration Eligibility
 
Registration/Eligibility Form
 
Annual Medical Record Release Authorization Tem  
 
Pulmonary Function Test Form
 
 
 
Participant-Completed Questionnaires:
 
Demographic/Health Status Questionnaire
  
Smoking Status Questionnaire
 
Baseline Health Status Questionnaire
 
Annual Health Status Questionnaire  
 
Health Status Questionnaire
 
Coversheet for Quality of Life Questionnaires
 
 
 
Biomarkers:
 
Biomarker Collection Form  
Specimen Packing Form (Blood/Urine)  
 
Sputum Transmittal Form
 
 
 
 
 
 
 
Imaging Forms:
 
Screening CT Form  
Screening Chest Radiograph (CXR)   
Historical Images Form - CXR  
Historical Images Form - CT  
(CT/CXR) Screening Result Form
CT Images  
 
CXR Images
 
 
 
Follow-up Forms:
 
Interval Follow-Up Questionnaire 
Interval Follow-Up Coversheet 
Follow-Up Supplement
 
 
 
 
1-Year Follow-up Coversheet  
1.5-Year Follow-up Coversheet
 
2-Year Follow-up Coversheet  
 
2.5-Year Follow-up Coversheet
 
3-Year Follow-up Coversheet 
 
3.5-Year Follow-up Coversheet
 
4-Year Follow-up Coversheet  
 
4.5-Year Follow-up Coversheet
 
5-Year Follow-up Coversheet 
 
5.5-Year Follow-up Coversheet
 
6-Year Follow-up Coversheet  
 
6.5-Year Follow-up Coversheet
 
7-Year Follow-up Coversheet  
 
7.5-Year Follow-up Coversheet
 
8-Year Follow-up Coversheet  
 
Interval Follow-Up Form
Additional ERs - F2 Supplement
Additional Hospitals - F2 Supplement  
Additional Providers - F2 Supplement  
Interval Follow-Up Form
Interval Follow-Up Form (writable version)
Follow-up Procedure Form 
    F4 Sample Phone Script
     
Abstraction Forms:
 
Summary Sheet
 
Diagnostic Evaluation Form
 
Emergency Room Visits
 
Hospital Admissions
 
Primary Lung Cancer
 
Outpatient Provider Visits
 
Pathology Samples
 
Diagnostic Evaluation Form
 
Cancer Progression Form
 
Treatment Form- Initial
 
Treatment From - Subsequent
 
 
 
Additional Forms and Worksheets:
 
RT                 Remnant Tissue Transmittal
CC 
Cancer Notification Form 
NP 
Non-Participation Form  
PR 
Protocol Variation Form  
General Communication Memo
RM 
Remnant Tissue Collection Form  
 
Adverse Events
 
FL 
Follow-up to Positive Screen With No Reported F/U
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Spanish Versions:
 
Pre-Registration Elig Worksheet - Spanish Version
 
DP 
Demographic/Health Status Questionnaire -Spanish Version
  
Smoking Status Questionnaire - Spanish Version  
 
QP 
Baseline Health Status Questionnaire - Spanish Version
 
QL 
Annual Health Status Questionnaire - Spanish Version  
 
Health Status Questionnaire - Spanish Version  
 
Contact Sheet Spanish Version
 
 
 
 
 
Equipment QC Forms:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endpoint Verification Process:
 
 
 
 
 
 
 
National Death Index:
ND           NDI Results Form                                                      ND Instructions
 
 
 
For additional information regarding Adverse Events,
please visit ACRIN’s Protocol Development and Regulatory Resources page:
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