1. Patient/Alternate Contact Person(s) Information Instructions
Randomization Number
Patient/Alternate Contact Person(s) Information Instructions
General
Instructions
This contact information will be used to:
determine survival status
complete the 6 month follow-up questionnaires.
Obtain as much different contact information as you are able to for each of the following:
patient
person(s) living with the patient
persons who do not live with the patient (recommend at least 2 alternate contacts not living with the patient)
These data are to be collected once, at consent or baseline.

2. Patient/Alternate Contact Person(s) Information Form
Randomization Number
Patient/Alternate Contact Person(s) Information Form
Participant contact information: (verify contact information with medical record or alternate)
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Name, First Name Middle Name
alternate name (i.e. nicknames/alias): □ None #1 _ _ _ _ _ _ _ __ _ _ _ _ _ _ #2 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Someone who lives with participant:
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Name, First Name Middle Name
Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Someone with a different address from participant: (obtain complete information for at least 2 people)
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Name, First Name Middle Name
Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Name, First Name Middle Name
Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Name, First Name Middle Name
Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available
Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _