2 questionaire

Supporting Statement A
Attachment 4
Next of Kin Questionnaires

NEXT-OF-KIN FORMS

Study Participation Status
Search to Locate Participant
Retention Worksheet
Initial Notification of Death

WHI

Form 9 – WHI Extension Study Participation Status

Ver. 8.1

OMB # 0925-0414 Exp: 05/09

COMMENTS:

- Affix label hereMember ID: __ __

__ __ - ___ ___ ___ - ___

First Name ________________________M.I.______
Last Name _________________________________

1. Effective Date:

-

2. Completed By:

-

-

(M/D/Y)

3. Source of Information:
Participant

…1
…4 FC Staff
…2 Family Member or Friend …8 Other
…3 Physician
…5 CCC Database Update

4. Change in Follow-Up Status. If participant is changing her follow-up status at this contact, mark the new follow-up
status. (Mark only one.)

…1 Full follow-up
…2 Proxy follow-up (Complete 4.1 only if applicable.)
Proxy Name: ______________________________________
Relationship: ______________________________________
Address:

______________________________________
______________________________________

Phone Number(s):___________________________________
Reason:___________________________________________
(Enter the Proxy information in the Personal Information Update screen.
Notify proxy and request permission.

4.1.

Type of follow-up (for
codes 2 and 4).

…2 No phone
…3 No CCC mail

…4 Partial or Custom follow-up (Complete 4.1 only if applicable)
(Contacts customized to meet specific participant needs.) Specify:

…5 No follow-up (OK to have periodic contact with participant)
…8 Absolutely no contact (No contact with participant)
Complete Form 120 – Initial Notification of Death (do not complete Form 9).
…6 Deceased
Complete Form 23 – Search to Locate Participant (Vital Status Investigation)
…7 Lost-to-follow-up
(do not complete Form 9).
5. Change in Newsletter Status:

…0 Refuse Newsletter
…1 Receive Newsletter
Comments:

K _________
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WHI

Form 23 - Search to Locate Participant

Ver. 8.1
OMB # 0925-0414 Exp: 5/09

Comments:

- Affix label hereMember ID: __ __

__ __ - ___ ___ ___ - ___

First Name ________________________M.I.______
Last Name _________________________________

Complete questions 1, 2, and 3 to initiate a search. Complete questions 4, 5 and 6 at conclusion of
search. Complete Question 7 to document all attempts to locate participant.
1.

Background of search
1.1 Date of last contact with the WHI FC: ___ ___ - ___ ___ - ___ ___ (M/D/Y)
1.2 Reasons for starting the search (more than one may apply):
___ WHI Extension Study participant has been identified as “lost to follow-up (e.g., appears on
WHIX 1591 – Participants Who Are Lost to Follow-up)
___ Incorrect, incomplete, or invalid mailing address
___ Telephone number is incorrect, disconnected, or no longer in service (optional search)
___ Other (Specify): _______________________________

2. Initiation Date:

-

3. Initiated By:

-

-

(M/D/Y)

Data enter questions 4, 5, and 6 at conclusion of search. (Update existing key-entered form; do not start a new
form. Complete Form 9 – Participation Status for a change in participant follow-up status.)

-

-

(M/D/Y)

4.

Date Search Ended:

5.

Search Ended By:

6.

Search Result: (Required at conclusion of Lost-To-Follow-Up search)

…1

…4

-

The participant has been located.
(If participant was lost-to-follow-up and has been found, complete and key enter Form 9 – Participation
Status with updated follow-up status information.)
(Includes deceased participants. Complete Form 120 – Initial Notification of Death for a participant
identified as deceased.)
The participant could not be located.

Comments: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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WHI

7.

Form 23 - Search to Locate Participant

Ver. 8.1

Record of attempts to locate a participant. Complete and document all relevant tasks associated
with the Vital Status/Lost-to-Follow-Up search. (Use any, all, or other sources as available.) Note:
all tasks may not apply.
Check activities
completed

a)

Check local telephone directory for current telephone number and current address. ........................................

_____

b)

Check with directory assistance for current phone number. ...............................................................................

_____

c)

Make phone calls to participant’s home to verify address ................................................................................

_____

d)

Mail a letter to the last known address for the participant, requesting that she contact
the FC ...................................................................................................................................................................

_____

Date_______________
e)

Date_______________

Date_______________

Make phone calls to personal contacts listed on Personal Information Update................................................
Date_______________

Date_______________

_____

Date_______________

f)

Contact any other sources listed on Personal Information Update.................................................................

_____

g)

Consult reverse directory (Polk or Coles) and contact current resident
and/or neighbors at last known address. .......... ...............................................................................................

_____

Make phone calls to physician/medical contacts...............................................................................................

_____

h)

Date_______________

Date_______________

Date_______________

i)

Consult Post Office for current address.............. ...............................................................................................

_____

j)

Mail a certified letter (marked “restrictive delivery”) to the last known address for the participant,
requesting that she contact the FC .......................................................................................................................

_____

Date_______________

Date_______________

k)

Check with the Department of Motor Vehicles for current address. ...................................................................

_____

l)

Check with Social Security Administration for vital status. ................................................................................

_____

m) Conduct Internet search for lost-to-follow-up participant. See Form 23 Instructions for a variety of web sites.

_____

n)

_____

Other (specify): ................................................. ...............................................................................................

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WHI

Form 24 – Retention Worksheet

Ver. 8

- Affix label here-

Comments

Member ID: __ __

__ __ - ___ ___ ___ - __

First Name _______________________M.I.______
Last Name ________________________________

FOLLOW-UP CONTACTS

Personal /
Family

Travel /
Scheduling

Other

Contact
Type

Reason for
Problem*
(Check All That
Apply)

Contact Note:

1

2

8

Contact Note:

1

2

8

Contact Note:

1

2

8

Contact Note:

1

2

8

Contact Date
(m/d/y)

Staff ID

1 = Phone
2 = Mail
8 = Other

Participation
Level
0 = None
1 = Low
2 = Full

Continue
Contacts?
0 = No
1 = Yes

Recontact
Date (m/d/y)

Data
Entry
Initial/
Date

* Reason for Problem: 1 = Personal/Family issues, 2 = Travel/Scheduling problems, 8 = Other
Note: If participation status has changed when retention activities have ended, complete
Form 9 – Participation Status.

_____________________________________________________________________________________________
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