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Version Date: 10/99 Expiration Date: 10/02,Form Approved OMB No.: 0925-0407 |
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Participant ID Number, |
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"Prostate, Lung, Colorectal and Ovarian", |
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Cancer Screening Trial, |
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BASELINE QUESTIONNAIRE FOR MALE, |
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PARTICIPANTS (BQM3), |
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PLEASE COMPLETE:, |
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Participant Name: _____________________________________________________________________, |
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First Middle,Last |
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Participant Date of Birth: _______________________________________________________________, |
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Month,Day Year |
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Participant Telephone Number: (), |
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INSTRUCTIONS, |
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"• Do not fold, staple or tear the pages of this form.", |
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• Use a #2 PENCIL to mark your answers., |
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• Make heavy black marks that fill the circle completely., |
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"• If you need to change an answer, be sure to erase completely.", |
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"• Mark only one response for each question, unless the instructions tell you otherwise.", |
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• Some questions ask you to write your answer in the space provided., |
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• Some questions also have additional instructions next to certain answers. These instructions, |
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may either ask you to skip questions that do not apply to you or ask you to provide additional, |
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"information. First darken the appropriate circle, then follow the instructions as directed. Unless", |
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"instructed otherwise, go to the next question.", |
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CORRECT MARK INCORRECT MARKS, |
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