Visit 19 Form Versions |
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Note: The most
current versions are in red. |
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FOLLOW-UP INTERVIEW/EXAM FORMS |
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Form# |
Title |
Versions |
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F07 |
Physical Exam |
08/15/94c |
04/01/95 |
8/1/95 |
10/1/98 |
4/1/99a |
10/1/99b |
4/1/01a |
10/1/01 |
10/1/02 |
4/1/03 |
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F07 (cont) |
Physical Exam |
10/1/03 |
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F08 |
Gynecological Exam |
8/15/94d |
4/1/95d |
10/1/98 |
4/1/99a |
10/1/99 |
04/01/00 |
4/1/01 |
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F08a |
Potential CVL
Contaminants |
10/15/95 |
10/1/98 |
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F21 |
Sociodemographics |
4/1/95 |
10/1/98b |
4/1/02 |
10/1/02 |
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F22* |
Medical & Health
History |
04/01/95c |
8/1/95 |
3/1/96 |
8/15/96 |
10/1/98b |
4/1/99b |
10/1/99a |
4/1/00a |
10/01/00 |
4/1/01a |
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F22* (cont) |
Medical & Health
History |
10/1/01b |
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F22HX |
Medical & Health
History |
10/1/02a |
4/1/03a |
10/1/03a |
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F22MED |
Medical & Health
History |
10/1/02 |
4/1/03a |
10/1/03 |
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F23 |
OB/GYN History |
04/01/95c |
8/1/95 |
3/1/96 |
10/1/98c |
10/1/99 |
4/1/00 |
10/01/00a |
10/1/02 |
4/1/03b |
10/01/03 |
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F23a* |
Fertility and
Infertility History (visit 14 substudy) |
04/01/01a |
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F24 |
Alcohol, Drugs &
Sexual Behavior |
4/1/95 |
8/10/95 |
6/15/97 |
10/1/98a |
4/1/99 |
10/1/99a |
4/1/00a |
10/1/01a |
10/1/02 |
04/01/03 |
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F24 (cont) |
Alcohol, Drugs &
Sexual Behavior |
10/1/03a |
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F25 |
Health Care
Utilization |
04/01/95c |
10/1/98a |
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F25a* |
Health Care
Utilization Supplement |
8/1/95 |
10/1/98a |
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F26 |
Psychosocial |
4/1/95 |
10/1/98d |
10/1/03 |
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FHX* |
Family and Personal
History |
10/1/00 |
10/1/01b |
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DRUG1 |
Antiretroviral
Medications |
10/1/98 |
4/1/99 |
10/1/99a |
4/1/00a |
10/1/00b |
10/1/01a |
10/1/02a |
4/1/03a |
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DRUG2 |
Non-antiviral
Medications |
10/1/98 |
4/1/99c |
10/1/00c |
10/1/03 |
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DRUG3 |
Antiviral Medications |
10/1/02a |
4/1/03b |
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*Discontinued |
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SPECIMEN COLLECTION FORMS |
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Form# |
Title |
Versions |
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F10 |
Plasma & Cell
Separation and Freezing |
8/15/94 |
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F29 |
Blood Specimen
Collection Form |
4/1/95 |
8/1/95 |
3/1/96a |
4/1/00 |
10/1/00 |
4/1/01 |
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F29a |
Antiviral Usage
Assessment for Blood Draw |
10/1/99b |
10/1/00a |
10/1/01a |
10/1/02 |
4/1/03a |
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F31 |
Specimens Collected
During PE |
4/1/95 |
8/1/95 |
4/1/99 |
10/1/99 |
4/1/00 |
10/1/02 |
4/1/03 |
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LOCAL LAB FORMS |
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Form# |
Title |
Versions |
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L01 |
HIV ELISA and Western
Blot |
8/15/94 |
10/1/98 |
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L02 |
Serum Antibody Tests
- Hepatitis |
8/15/94 |
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L03 |
Automated
CBC/Differential |
8/15/94a |
10/1/00 |
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L03a |
Hand-Manual
Differential |
8/15/94 |
10/1/00 |
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L04 |
Flow Cytometry |
8/15/94 |
10/15/96 |
10/1/98b |
10/1/00 |
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L05 |
Liver/Renal Function
Tests |
8/15/94c |
4/1/02 |
10/1/02 |
4/1/03 |
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L06 |
Serum Antibody Tests
- Syphilis Screening |
8/15/94c |
10/1/01 |
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L08* |
PPD Skin Test |
8/15/94 |
1/15/95 |
10/1/99 |
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L10 |
Urinalysis |
8/15/94 |
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L11 |
Urine Culture Results |
8/15/94 |
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L12 |
(Urine) Pregnancy
Test |
8/15/94d |
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L14 |
Colposcopy Results |
8/15/94c |
5/1/95 |
9/15/95 |
4/1/00 |
10/1/00 |
10/1/02a |
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L15 |
Biopsy Histopathology
Pelvic Exam |
8/15/94d |
5/1/95 |
9/15/95 |
4/1/99a |
10/1/02 |
4/1/03 |
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L16 |
Dysplasia Treatment |
8/15/94 |
5/1/95 |
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L17 |
Herpes Culture of
Ulcers and Fissures |
8/15/94 |
10/15/94 |
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L18 |
Trichomonas Vaginalis
Culture |
8/15/94 |
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L19 |
CVL Processing |
8/1/96 |
2/15/97 |
8/25/97 |
3/14/98 |
10/1/98a |
10/1/99 |
10/1/01 |
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*Discontinued |
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CENTRAL LAB FORMS |
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Form# |
Title |
Versions |
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C31 |
Human Retrovirus Testing |
04/01/95c |
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C45 |
Bacterial Vaginosis
Smear Gram Stain |
8/15/94 |
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C50 |
Urine for Chlamydia |
8/15/94 |
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C52 |
HPV by PCR |
8/1/95 |
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C54 |
Viral Load |
12/16/96 |
10/1/98 |
4/1/00 |
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C60 |
Pap Smear |
8/15/94 |
10/1/98 |
4/1/99 |
4/1/02 |
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C60a |
Pap Smear
Retrospective Re-Read v1-15 |
4/1/03 |
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C60b |
Pap Smear Retrospective Re-Read
v16 |
4/1/03 |
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C65 |
Syphilis DFA -
Genital Ulcers & Fissure |
8/15/94 |
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C66 |
Serum Antibody
Type-Specific Herpes Serology |
1/6/97 |
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C70 |
Laboratory -
Stimulated Saliva Evaluation |
10/15/96a |
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C71 |
Laboratory -
Subgingival Plaque |
10/15/96 |
4/1/99a |
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C72 |
Laboratory -
Erythematous Candidiasis Smear Results |
4/1/99a |
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ADMINISTRATIVE FORMS |
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Form# |
Title |
Versions |
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ABRV |
Abbreviated Visit |
07/11/97 |
8/1/97 |
4/1/00 |
10/1/01a |
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ANTHRO |
Anthropometry
Training Form |
4/1/99 |
10/01/02a |
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DENR |
Disenrollment Form |
9/1/95 |
8/1/96 |
6/15/97 |
10/1/98a |
4/1/99c |
10/1/00 |
4/1/03 |
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INT |
Interim Events Form |
4/1/99 |
10/1/99 |
10/1/00b |
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MVIS |
Missed Visit Form |
10/1/95 |
8/1/96 |
10/1/98a |
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REF |
Referral Checklist |
4/1/00 |
10/01/01 |
4/1/02 |
4/1/03 |
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TRAN |
Transfer Form |
9/1/95 |
10/1/98 |
10/1/01a |
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OUTCOMES ASCERTAINMENT FORMS |
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Form# |
Title |
Versions |
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ACS |
Ascertainment Control
Sheet (QxQs only) |
10/1/98 |
04/01/99c |
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ATC |
Ascertainment
Tracking Checklist |
10/1/98a |
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CNCR |
Cancer Registry Case
Report |
5/20/99a |
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CORE |
Clinical Outcomes
Reporting Form |
10/1/98 |
11/16/98 |
4/1/99c |
10/1/00 |
4/1/01a |
4/1/03 |
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TB |
TB - Verified Case
Report |
1/12/99 |
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PREGNANCY PROTOCOL FORMS |
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Form# |
Title |
Versions |
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PRNOTI |
Enrollment |
04/01/99a |
10/1/99 |
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PR01 |
Pregnancy Form |
04/01/99b |
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PR02 |
Post-partum Form |
04/01/99d |
10/1/03 |
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ACSR PROTOCOL FORMS |
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Form# |
Title |
Versions |
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ACSR ATC |
ACSR Ascertainment
Tracking Checklist |
04/01/99b |
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QCGY |
QC Review of
Gynecologic Material |
10/1/00 |
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QCSS |
QC Central Review of
Surgical Specimens |
10/1/00 |
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ORAL PROTOCOL FORMS |
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Form# |
Title |
Versions |
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OP01 |
Medical Evaluation |
3/1/95 |
10/01/95c |
10/01/98a |
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OP02 |
Research Interview |
3/1/95 |
10/1/98 |
4/1/03 |
10/1/03 |
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OP03 |
Saliva Sample
Collection |
3/1/95 |
9/1/96 |
10/1/98 |
04/01/99a |
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OP04 |
Oral Mucosal Tissue
Exam |
3/1/95 |
9/1/96 |
10/01/98a |
4/1/00 |
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OP04a |
Addendum |
3/1/95 |
10/01/98a |
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OP05 |
Smear Results |
3/1/95 |
10/1/98 |
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OP06 |
Tooth Count &
Random Half Mouth |
03/01/95c |
10/1/98 |
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OP07 |
Plaque Index |
3/1/95 |
10/1/98 |
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OP08 |
Gingival Banding
Score |
3/1/95 |
10/1/98 |
4/1/03 |
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OP09 |
Papillary Assessment |
3/1/95 |
10/1/98 |
4/1/03 |
10/1/03 |
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OP10 |
Subgingival Plaque |
3/1/95 |
7/1/97 |
10/1/98 |
4/1/03 |
10/1/03 |
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OP11 |
Coronal Caries |
3/1/95 |
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OP12 |
Root Caries |
3/1/95 |
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OP13 |
Gingival Bleeding |
3/1/95 |
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OP14 |
Loss of Attachment |
3/1/95 |
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OP15 |
Dental Prostheses |
03/01/95c |
10/1/98 |
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OP16 |
Oral Referral and F/U |
03/01/95c |
10/1/98 |
04/01/99a |
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OPNOTI |
Oral Protocol
Participant Notification (expansion) |
3/1/95 |
10/01/01 |
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NIDA I/V FORMS* |
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Form# |
Title |
Versions |
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NI01 |
Health Care
Utilization Collaborative WIHS/HERS Interview |
10/1/98 |
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NV01 |
Enrollment Interview |
11/15/97 |
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NV03 |
Specimen Collection |
11/15/97 |
10/1/98 |
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NV04 |
Specimen Processing |
11/15/97 |
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NV05 |
Flow Cytometry |
11/15/97 |
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NV07 |
Urine Toxicology |
11/15/97 |
10/1/98 |
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NVNOTI |
Participant
Notification |
11/15/97 |
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*discontinued |
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HHV-8 SUBSTUDY FORMS |
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Form# |
Title |
Versions |
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HVDENR |
Disenrollment |
4/1/99 |
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HVMVIS |
Missed Visit |
4/1/99 |
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HVNOTI |
Recruitment Outcome
Form |
4/1/99 |
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HVSPEC |
Specimen Collection |
4/1/99 |
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VISIT 18/19 SUBSTUDIES: PK, SEX STEROID, METABOLIC |
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Form# |
Title |
Versions |
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PK01 |
Eligibility for Intensive PK
Stubstudy |
4/1/03 |
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PKNOTI |
PK: Participant notification |
4/1/03 |
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PK02 |
PK: Current Antiretroviral medication
use |
4/1/03a |
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PK02a |
PK: Antiretroviral adherence |
4/1/03 |
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PK03 |
PK: Recent illnesses, concurrent meds
& OB/GYN hist |
4/1/03a |
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PK04 |
PK: Recent substance use |
4/1/03 |
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PK05a |
PK: Weight and
Specimen collection: group A |
4/1/03a |
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PK05b |
PK: Weight and Specimen collection:
group B |
4/1/03 |
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PK05c |
PK: Weight and Specimen collection:
group C |
4/1/03a |
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PK06 |
PK: Dosing of antiretroviral
medications |
4/1/03a |
10/6/03 |
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PK07 |
PK: Plasma Separation and Freezing
Form |
4/1/03 |
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PK08 |
PK: Dietary Fat Percentage
Questionnaire |
5/14/03a |
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PK-DIET |
PK: Dietary Assessment |
4/1/03a |
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MSSCR |
MS: Screening form |
4/1/03 |
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MSNOTI |
MS: Participant notification |
4/1/03 |
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MS01 |
MS: Specimen Collection for Metabolic
Study |
6/13/03a |
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MS02 |
MS: Lab test report form |
4/1/03 |
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MS03 |
MS: DXA scan form |
4/1/03 |
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SSNOTI |
SS: Participant notification |
4/1/03 |
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SS01 |
SS: Sex steroid lab test report form |
4/1/03 |
10/1/03 |
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SSSCR |
SS: Sex steroid screening form |
4/1/03a |
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FOLLOW-UP INTERVIEW/EXAM FORMS (SPANISH) |
|
Form# |
Title |
Versions |
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ABRV |
Abbreviated Visit |
4/1/00 |
10/1/01a |
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DRUG1 |
Antiviral Medications |
10/01/98a |
04/01/99a |
10/1/99 |
04/01/00a |
10/01/00b |
10/1/01a |
10/1/02a |
4/1/03a |
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DRUG2 |
Non-antiviral
Medications |
10/1/98 |
04/01/99c |
10/01/00c |
10/1/03 |
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DRUG3 |
Antiviral Medications |
10/1/02a |
4/1/03b |
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F07 |
Physical Exam |
04/01/99a |
10/01/99b |
04/01/01a |
10/01/01 |
10/1/02 |
4/1/03 |
10/1/03 |
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F21 |
Sociodemographics |
4/1/95 |
10/01/98c |
4/1/02 |
10/1/02 |
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F22* |
Medical & Health
History |
04/01/95c |
8/1/95 |
3/1/96 |
8/15/96 |
10/01/98a |
04/01/99b |
10/1/99 |
04/01/00a |
10/1/00 |
04/01/01a |
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F22* (cont) |
Medical & Health
History |
10/1/01b |
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F22HX |
Medical & Health
History |
10/1/02a |
4/1/03a |
10/1/03 |
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F22MED |
Medical & Health
History |
10/1/02 |
4/1/03a |
10/1/03 |
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F23 |
OB/GYN History |
04/01/95c |
8/1/95 |
3/1/96 |
10/01/98c |
10/1/99 |
4/1/00 |
10/1/00a |
10/01/02 |
4/1/03a |
10/1/03 |
|
F23a* |
Fertility and
Infertility History (visit 14 substudy) |
04/01/01a |
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F24 |
Alcohol, Drugs &
Sexual Behavior |
4/1/95 |
8/1/95 |
6/15/97 |
10/01/98b |
4/1/99 |
10/1/99 |
04/01/00a |
10/1/01a |
10/01/02 |
4/1/03 |
|
F24 (cont.) |
Alcohol, Drugs &
Sexual Behavior (cont.) |
10/1/03 |
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F25 |
Health Care
Utilization |
04/01/95c |
10/01/98b |
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F25a* |
Health Care
Utilization Supplement |
8/1/05 |
10/01/98a |
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F26 |
Psychosocial |
4/1/95 |
10/01/98d |
10/1/03 |
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F29a |
Antiviral Usage
Assessment for Blood Draw |
10/01/99b |
10/01/00a |
10/1/01a |
10/1/02 |
4/1/03a |
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FHX* |
Family and Personal
History |
10/01/00 |
10/1/01 |
10/01/01a |
10/01/01b |
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INT |
Interim Events Form |
4/1/99 |
10/1/99 |
10/01/00c |
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MS01 |
MS: Specimen Collection for Metabolic
Study |
4/1/03 |
6/13/03a |
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PK02 |
PK: Current Antiretroviral medication
use |
4/1/03a |
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PK02a |
PK: Antiretroviral adherence |
4/1/03 |
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PK03 |
PK: Recent illnesses, concurrent meds
& OB/GYN hist |
4/1/03a |
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PK04 |
PK: Recent substance use |
4/1/03 |
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SSSCR |
SS: Sex steroid screening form |
4/1/03a |
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OP02 |
Oral Interview |
3/1/95 |
10/1/98 |
4/1/03 |
10/1/03 |
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*Discontinued |
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|
EXPANSION FORMS* |
|
Form# |
Title |
Versions |
|
|
|
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|
|
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|
EL |
New Recruit
Eligibility Form |
10/1/01a |
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F07R |
Physical Exam
Addendum |
10/01/01 |
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F20 |
New Recruit Baseline
History (English) |
10/01/01 |
4/1/02 |
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F20 |
New Recruit Baseline
History (Spanish) |
10/01/01 |
4/1/02 |
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F20a |
New Recruit Baseline
History: Addendum (English) |
01/01/02 |
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F20a |
New Recruit Baseline
History: Addendum (Spanish) |
01/01/02 |
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F22r |
New Recruit ART
History (English) |
4/1/02a |
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F22r |
New Recruit ART
History (Spanish) |
4/1/02a |
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F29R |
Blood Specimen
Collection Form |
10/01/01 |
|
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F31R |
Specimens Collected
During PE |
10/1/01a |
|
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|
L09 |
Chlamydia LCR
Gen-Probe |
8/15/94 |
10/01/01 |
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L13 |
Gonorrhea LCR |
8/15/94 |
10/01/01 |
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|
RAB |
Retrospective Medical
Record Abstraction |
10/01/01a |
|
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|
RAB Appen. |
Retrospective Medical
Record Abstraction Appendix |
10/01/01b |
|
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|
S2 |
New Recruit Sreening
Form (English) |
10/1/01b |
|
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|
S2 |
New Recruit Sreening
Form (Spanish) |
10/1/01a |
|
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|
*discontinued |
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