PVDOMICS STUDY FORMS and DATA TRANSMISSION FORMATS TABLE OF CONTENTS – as of 02/08/2024
Form #	Version Date*	Form Name
CENTER SPECIFIC FORMS
db_acct	09/18/2018	Data Entry Account Request Form
secure_acct	11/28/2016	Secure Transfer Account Request Form
Borg	--	Borg Dyspnea Scale
09	08/14/2020	Clinical Center Form
10	11/28/2016	Study Personnel Form
CENTER PARTICIPANT FORMS
---	04/10/2016	Participant Contact Information and Pre-Screening Sheet (not entered into study database)
100	10/25/2017	Initial Enrollment Form (includes Inclusion and Exclusion Review questions)
102	08/03/2021 08/03/2021	PVD Assessment Form 102C-Comparators Only Assessment
103	10/30/2018	Non-PVD Comorbidity, Medical and Surgical History Form
104	04/04/2016	Demographics, Employment and Income Form
105	08/23/2018	Exposure History Form
106	11/09/2017	Thrombophilia History Form
107	06/17/2021	Review of Family History of Pulmonary Hypertension Form
110	06/23/2017	PH and Concomitant Medications Form
115	05/08/2019	Functional Class
120	06/23/2017	Study Visit Vital Signs Form
121	02/21/2018	Female Reproductive History Form
131	07/20/2017	Waist/Hip Measure Form
132	06/08/2017	Height, Weight, and Bioelectrical Impedance (BIA) Form
133	06/15/2018	6 Minute Walk Test (6MWT) Form
138	09/12/2018	Center Acknowledgment of Core Incidental Findings Form
150	01/10/2019	Clinical Center Participant Initial Sleep Form
151 151Admin	09/19/2016 11/29/2017	Participant Sleep Study Questionnaire Administration Form for Sleep Study
152	01/10/2019	Clinical Center Sleep Download and Transmittal Form
155	04/04/2018	Clinical Center Alternative Sleep Study Report Transmission Form
170E	05/25/2016	Survey Instrument (SF-36v2) Form – English (administration form included at end of document)
170S 170Admin	07/12/2016	SF-36v2 Questionnaire – Spanish, Administration Form for SF-36v2 Questionnaire - Spanish
170S 170Admin	07/12/2016	SF-36v2 Questionnaire – Spanish, Administration Form for SF-36v2 Questionnaire - Spanish
171E	04/05/2016	Minnesota Living With Heart Failure® Questionnaire (MLHF) – English (administration form included at end of document)
171S 171Admin	07/12/2016	MLHF Questionnaire Packet Form – Spanish, Administration Form for MLHF Questionnaire – Spanish
172E	04/08/2016	emPHasis-10 Quality of Life Form – English (administration form included at end of document) emPHasis-10 darker print version
172S 172Admin	08/10/2016	emPHasis-10 Questionnaire – Spanish, Administration Form for emPHasis-10 Questionnaire – Spanish
185	10/01/2018	Participant Two-Week Event Assessment
187	01/09/2023	Annual Follow-up
200	08/22/2017	Center CBC w Diff Results
201	01/11/2018	Center Complete Metabolic Panel (CMP) Results
202	09/17/2019	Center Antinuclear Antibody (ANA) Results
203	06/23/2017	Center HIV Antigen/Antibody Screen Result
204	02/23/2018	Center Hepatitis Screen Result
205	06/23/2017	Center Prothrombin Time (PT) Results
206	06/23/2017	Center Pregnancy Test Results
207	11/10/2017	Center Arterial Blood Gases (ABG) Results
245	01/20/2017	Center Electrocardiogram (ECG) Data Transmittal Form
250	02/27/2019	Echocardiogram (ECHO) Transmittal Form
251	08/31/2017	Cardiac MRI Transmittal Form
252	02/22/2018	Center Chest CT Scan Data Transmittal Form
253	07/05/2017	Center Historical Chest CT Data Transmittal Form
254	07/09/2018	Center Ventilation/Perfusion (V/Q) Scan Report
270	10/27/2017	Pulmonary Function Testing
271	10/10/2017	Historical Pulmonary Function Testing
280	02/27/2019	Clinical Center Right Heart Catheterization (RHC)
290 290A	08/01/2018 05/24/2018	Center Cycle Ergometer Non-Invasive CPET Procedure Notes Addendum to Center Cycle Ergometer Non-Invasive CPET Procedure Notes
291 291A	08/01/2018 05/24/2018	Center Cycle Ergometer Invasive CPET Procedure Notes Addendum to Center Cycle Ergometer Invasive CPET Procedure Notes
300	02/16/2017	Center Blood Collection 1 – Drawing Samples Form
301	02/16/2017	Center Blood Collection 1 – Processing Samples Form
303	09/21/2017	Center Blood Collection – Shipping of Frozen Cryovials and PAXgene® Tubes to Biorepository Form
304	03/03/2020	Center Blood Collection 2 – Drawing “Rest” Samples Form
305	05/23/2018	Center Blood Collection 2 – Processing PAXgene® “Rest” Sample Form
306	05/23/2018	Center Blood Collection 2 – Processing “Rest” Samples into Cryovials Form
307	05/23/2018	Center Blood Collection 2 – Drawing “Rest, Peak and Post” Samples Form
308	05/23/2018	Center Blood Collection 2 – Processing PAXgene® “Rest, Peak and Post” Sample Form
309	05/23/2018	Center Blood Collection 2 – Processing “Rest, Peak and Post” Samples into Cryovials
320	02/16/2017	Center Urine Collection 1 Sample
321	02/16/2017	Center Urine Collection 1 Processing Sample
330	11/01/2016	Center BTS System Specimen Storage Log
335	06/22/2017	Center BTS System ROOM TEMP Specimen Log and Shipment Form
336	11/01/2016	Center BTS System FROZEN Specimen Shipment Log
340	10/27/2016	Biorepository Emergency Supplies Request
400	03/22/2018	Event(s) Notification Form
401	07/10/2019	Detailed Adverse Events Form
402	10/27/2016	Event Information Sent to the DCC Form
410	03/07/2018	Center Request for Extension of Study Procedures
411	10/30/2018	Center Request for Exception
412	12/10/2019	Drop-Out
420	08/29/2018	Center Study Completion and Forever Missing Data
900	09/15/2021	COVID-19 Vaccination Details Form Combined PVDOMICS and LPVDOMICS
DCC CORE FORMS ONLY
153	04/02/2018	Sleep Core Receipt and QA Review
154	02/08/2018	Sleep Core Incidental Findings
156	11/13/2018	Sleep Core Review of Alternative Sleep Study Form
220	12/20/2019	Clinical Chemistry Core Results Data Transmission
246	08/06/2018	CPC Electrocardiogram (ECG) Core Results Form
246A	02/08/2024	Electrocardiogram (ECG) Extra Measures
247	03/06/2018	CPC ECG Incidental Findings Form
256	01/12/2017	Core Review of Historical V/Q Scan Form
260	10/26/2017	ICL Core Echocardiogram (ECHO) Results Data Transmission
261	10/19/2018	ICL Core Cardiac MRI Imaging Results Data Transmission
262	05/14/2020	Lung Imaging Core (CT) Results
262A	03/03/2021	Lung Imaging PA Measures
262B	12/12/02023	CT Core CTEPH Extra Measures
263	03/12/2018	Lung Imaging Core (CT) Incidental Finding(s)
266	12/07/2017	Core Cardiac ECHO Incidental Finding(s)
267	12/07/2017	Core Cardiac MRI Incidental Finding(s)
283	08/02/2018	Core Right Heart Catheterization (RHC) Results
292	03/05/2021	CPC CPET Results
293	03/06/2018	CPC CPET Incidental Findings
294	10/01/2020	CPC CPET Results Subset
355	08/13/2017	Core BTS ROOM TEMPERATURE Specimen Received Log
356	01/24/2018	Core BTS FROZEN Specimen Received Log
357	07/26/2017	Core BTS Room Temperature Processing
358	07/12/2017	Core Room Temperature Log
360	08/22/2019	Core BTS Destroyed Specimen Log
361	02/25/2020	Core BTS Core Shipment Log
COMMITTEE REVIEW FORMS
700	02/25/2019	Adjudication Committee Reviewer Form
701	11/08/2018	Adjudication Committee Final Classification