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PVDOMICS STUDY
- FORMS TABLE OF CONTENTS |
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NOTES: ·
Administrative management forms and data are not included. ·
Some forms are included for informational purposes only. · PVD Status/WSPH WHO Group cases were adjudicated by a PVD committee of physician investigators. · Core adjudicated study results are provided where applicable. |
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Form
# |
Version Date |
CENTER
PARTICIPANT FORMS |
Notes |
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10/25/2017 |
Initial Enrollment Form (includes Inclusion and Exclusion Review questions) |
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08/03/2021 08/03/2021 |
PVD Assessment Form 102C-Comparators
Only Assessment |
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10/30/2018 |
Non-PVD Comorbidity, Medical and Surgical History Form |
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04/04/2016 |
Demographics, Employment and Income Form |
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08/23/2018 |
Exposure History Form |
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11/09/2017 |
Thrombophilia History Form |
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06/17/2021 |
Review of Family History of Pulmonary Hypertension Form |
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06/23/2017 |
PH and Concomitant Medications Form |
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05/08/2019 |
Functional Class |
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06/23/2017 |
Study Visit Vital Signs Form |
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02/21/2018 |
Female Reproductive History Form |
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07/20/2017 |
Waist/Hip Measure Form |
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06/08/2017 |
Height, Weight, and Bioelectrical Impedance (BIA) Form |
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06/15/2018 |
6 Minute Walk Test (6MWT) Form |
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01/10/2019 |
Clinical Center Participant
Initial Sleep Form |
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09/19/2016 |
Participant Sleep Study
Questionnaire |
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01/10/2019 |
Clinical Center Sleep
Download and Transmittal Form |
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04/04/2018 |
Clinical Center Alternative Sleep Study Report Transmission Form |
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05/25/2016 |
Survey Instrument (SF-36v2) Form |
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04/05/2016 |
Minnesota Living With Heart Failure® Questionnaire (MLHF) |
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04/08/2016 |
emPHasis-10 Quality of Life Form |
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10/01/2018 |
Participant Two-Week Event Assessment |
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01/09/2023 |
Annual Follow-up |
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08/22/2017 |
Center CBC w Diff Results |
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01/11/2018 |
Center Complete Metabolic Panel (CMP) Results |
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09/17/2019 |
Center Antinuclear Antibody (ANA) Results |
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06/23/2017 |
Center HIV Antigen/Antibody Screen Result |
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02/23/2018 |
Center Hepatitis Screen Result |
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06/23/2017 |
Center Prothrombin Time (PT) Results |
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11/10/2017 |
Center Arterial Blood Gases (ABG) Results |
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01/20/2017 |
Electrocardiogram (ECG) Data
Transmittal For |
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02/27/2019 |
Echocardiogram (ECHO) Transmittal
Form |
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08/31/2017 |
Cardiac MRI Transmittal Form |
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02/22/2018 |
Center Chest CT Scan Data Transmittal Form |
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07/05/2017 |
Center Historical Chest CT Data Transmittal Form |
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07/09/2018 |
Center Ventilation/Perfusion (V/Q) Scant |
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10/27/2017 |
Pulmonary Function Testing |
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10/10/2017 |
Historical Pulmonary Function Testing |
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02/27/2019 |
Clinical Center Right Heart
Catheterization (RHC) |
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08/01/2018 05/24/2018 |
Center Cycle Ergometer Non-Invasive CPET Procedure Notes Addendum to Center Cycle Ergometer Non-Invasive CPET Procedure Notes |
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08/01/2018 05/24/2018 |
Center Cycle Ergometer Invasive CPET Procedure Notes Addendum to Center Cycle Ergometer Invasive CPET Procedure Notes |
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02/16/2017 |
Center Blood Collection 1 – Drawing Samples Form |
Form provided
for information only. No data provided. |
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02/16/2017 |
Center Blood Collection 1 – Processing Samples Form |
Form provided
for information only. No data provided. |
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03/03/2020 |
Center Blood Collection 2 – Drawing “Rest” Samples Form |
Form provided
for information only. No data provided. |
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05/23/2018 |
Center Blood Collection 2 – Processing PAXgene® “Rest” Sample Form |
Form provided
for information only. No data provided. |
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05/23/2018 |
Center Blood Collection 2 – Processing “Rest” Samples into Cryovials Form |
Form provided
for information only. No data provided. |
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05/23/2018 |
Center Blood Collection 2 – Drawing “Rest, Peak and Post” Samples Form |
Form provided
for information only. No data provided. |
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05/23/2018 |
Center Blood Collection 2 – Processing PAXgene® “Rest, Peak and Post” Sample Form |
Form provided
for information only. No data provided. |
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05/23/2018 |
Center Blood Collection 2 – Processing “Rest, Peak and Post” Samples into Cryovials |
Form provided
for information only. No data provided. |
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02/16/2017 |
Center Urine Collection 1 Sample |
Form provided
for information only. No data provided. |
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02/16/2017 |
Center Urine Collection 1 Processing Sample |
Form provided
for information only. No data provided. |
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03/22/2018 |
Event(s) Notification Form – Events occurring within 8 week study period |
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Form
# |
Version
Date |
DCC CORE FORMS ONLY |
Notes |
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04/02/2018 |
Sleep Core Receipt and QA
Review |
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11/13/2018 |
Sleep Core Review of Alternative Sleep Study |
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12/20/2019 |
Clinical Chemistry Core Results Data Transmission |
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08/06/2018 |
CPC Electrocardiogram
(ECG) Core Results |
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02/08/2024 |
CPC
Electrocardiogram (ECG) Extra Measures |
Results will
be provided by an RFA team when finalized. |
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10/26/2017 |
ICL Core Echocardiogram (ECHO)
Results Data Transmission |
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10/19/2018 |
ICL Core Cardiac MRI Imaging Results
Data Transmission |
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05/14/2020 |
Lung Imaging Core (CT) Results |
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03/03/2021 |
Lung Imaging Core PA Measurements |
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12/12/2023 |
Lung Imaging Core (CT) CTEPH Measures |
Results will
be provided by an RFA team when finalized. |
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08/02/2018 |
Core Right Heart Catheterization (RHC) Results |
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03/05/2021 |
CPC CPET Results |
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