Accessibility issues or difficulties with this website?
Call 919-962-2073 or email hchsadministration@unc.edu.

Data Collection Forms

Data Collection Form Title Visit 1 English Visit 1 Spanish Visit 1 QxQ Visit 2 English Visit 2 Spanishsort descending Visit 2 QxQ Visit 3 English Visit 3 Spanish Visit 3 QxQ Visit 3 Answer Set
Tympanometry TYM
Neurocognitive Assessment NEE NES
Drop Point Selection DPS
Neurocognitive Assessment Template for Scoring DSS NEE
Household Screen and Roster Vers A HSRA HSRA
Occupation OCE OCS OCE
Household Screen and Roster Vers B HSRB HSRB
Oral Health OHE OHS OHE
Screening Call Tracking SCT SCT
Serious Adverse Event Form SAE SAE SAE PDF icon SAE PDF icon SAE
Personal Information PIE PIS PIE
Physical Activity PAE PAS PAE
Claudication CLE CLS CLE
Respiratory RSE RSS RS
Anthropometry Quality Control AQC AQC PDF icon AQC PDF icon AQC
Dietary Behavior DBE DBS DBE
Sleep SLE SLS SLE
Ankle Arm Blood Pressure ABP
Economic ECE ECS ECE
Social Network Index SNE SNS SNE
Anthropometry ANT ANT ANT PDF icon ANT PDF icon ANT
Health Care Use Vers B HCEB HCSB HCEB
Sociocultural SCE SCS SCE
Biospecimen Collection Form BIO BIO BIO BIO PDF icon BIO PDF icon BIO
Phantom Form PHT PHT PHT PDF icon PHT PDF icon PHT
Hearing Exam HEE HES HEE
Weight History WHE WHS WHE
Sitting Blood Pressure SBP SBP SBP PDF icon SBP PDF icon SBP
Hearing History HHE HHS HHE
Audiometry Examination AUD
Otoscopy OTO
Acculturation ACE ACS ACE
Alcohol Use ALE ALS ALE ALE ALS ALE
Tobacco Use TBE TBS TBE TBE TBS TBE PDF icon TBE PDF icon TBS PDF icon TBE PDF icon TBE AS
Well-Being WBE WBS WBE WBE WBS WBE
Participant Disability Screen PDE PDS PDE PDF icon PDE PDF icon PDS PDF icon PDE
Chronic Stress STE STS STE
Participant Feedback PFE PFS PFE
Family Cohesion FCE FCS FCE
Medical History MHE MHS MHE MHE MHS MHE PDF icon MHE PDF icon MHS PDF icon MHE PDF icon MHE AS
Personal Identifiers IDE IDS IDE IDE IDS IDE PDF icon IDE PDF icon IDS PDF icon IDE PDF icon IDE AS
Health Care Use Vers A/1 HCEA HCSA HCE HCS HCE PDF icon HCE PDF icon HCS PDF icon HCE PDF icon HCE AS
Socioeconomic Status/Occupation SEE SES SEE PDF icon SEE PDF icon SES PDF icon SEE PDF icon SEE AS
Medication Use MUE MUS MUE MUE MUE MUE PDF icon MUE PDF icon MUS PDF icon MUE PDF icon MUE AS
Pregnancy Complications PCE PCS PCE
Social Support SSE SSS SSE
Reproductive and Medical History RME RMS RME PDF icon RME PDF icon RMS PDF icon RME PDF icon RME AS