Study Name
* must provide value
Participant ID
* must provide value
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Borneo Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curacao Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Israel Italy Ivory Coast Jamaica Japan Java Jordan Kazakhstan Kenya Kiribati Kosovo Kurdistan Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Malawi Malaysia Mali Mauritania Metropolitan Denmark Metropolitan France Metropolitan Norway Metropolitan Portugal Metropolitan Spain Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Niue Fekai North America North Korea Northern Ireland Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Qatar Republic of Congo Republic of Ireland Romania Russia Rwanda Saint Kitts-Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Serbia Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Sri Lanka Sudan Sumatra Suriname Swaziland Sweden Switzerland Syria Tahiti Tajikistan Tanzania Tawain Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wales Western Sahara Yemen Yugoslavia (formerly) Zambia Zimbabwe
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Male
Female
Adult age category at enrollment
* must provide value
Adults (18 - 64 years)
Elderly (65 - 99 years)
Centenarians (100+ years)
Hispanic or Latino
Not Hispanic or Latino
Unknown (individuals not reporting ethnicity)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
More than One Race
Unknown or Not Reported
White
Note: this section pertains to past medical history only, not current symptoms.
Does the study participant have any past medical history?
* must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Please specify other general history
Yes No Not Specified N/A
Please specify other cardiovascular history
Yes No Not Specified N/A
Please specify other respiratory history
Gastrointestinal history? * must provide value
Yes No Not Specified N/A
Please specify other gastrointestinal history
Yes No Not Specified N/A
Please specify other pancreas/liver history
Kidney/Urological history? * must provide value
Yes No Not Specified N/A
Please specify other kidney/urological history
Yes No Not Specified N/A
Please specify other neurological history
Yes No Not Specified N/A
Please specify other blood/lymphatic history
Yes No Not Specified N/A
Please specify other musculoskeletal history
Head, Eyes, Ears, Nose, and Throat history? * must provide value
Yes No Not Specified N/A
Please specify other head, eyes, ears, nose, and throat history
Yes No Not Specified N/A
Please specify other immune diseases
Yes No Not Specified N/A
Please specify other cancer history
Yes No Not Specified N/A
Please specify other psychiatric history
Yes No Not Specified N/A
Please specify other dermatologic history
Yes No Not Specified N/A
Please specify other endocrine history
Obstetrics/Gynecology history? * must provide value
Yes No Not Specified N/A
Please specify other obstetrics/gynecology history
Infectious Disease history? * must provide value
Yes No Not Specified N/A
Please specify other infectious disease history
Does the subject have any family medical history?
* must provide value
Yes No Not Specified N/A
Please specify autoimmune disease family history
Please specify immunodeficiency family history
Please specify cancer family history
Please specify other family history
Please document the following:
Any vaccine administered 30 days prior to enrollment Any medication taken 30 days prior to enrollment Any immunosuppressant/ blood product received 90 days prior to enrollment. Any experimental product taken in the past year. Any chemotherapy, radiation therapy, or biological ever taken. This section is linked to RxNorm, a standardized medication database that provides normalized names for generic and branded clinical drugs. If you are unable to find the appropriate option in RxNorm, please specify at the bottom of this section.
Has the study participant taken any medications or received any vaccinations within the past 30 days?
* must provide value
Yes
No
Not Specified
N/A
How many medications/vaccinations?
10-Jan
Medication or Vaccination 1
Type to begin searching
Was there any information you were not able to include for medication or vaccination 1?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 1.
Medication or Vaccination 2
Type to begin searching
Was there any information you were not able to include for medication or vaccination 2?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 2.
Medication or Vaccination 3
Type to begin searching
Was there any information you were not able to include for medication or vaccination 3?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 3.
Medication or Vaccination 4
Type to begin searching
Was there any information you were not able to include for medication or vaccination 4?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 4.
Medication or Vaccination 5
Type to begin searching
Was there any information you were not able to include for medication or vaccination 5?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 5.
Medication or Vaccination 6
Type to begin searching
Was there any information you were not able to include for medication or vaccination 6?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 6.
Medication or Vaccination 7
Type to begin searching
Was there any information you were not able to include for medication or vaccination 7?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 7.
Medication or Vaccination 8
Type to begin searching
Was there any information you were not able to include for medication or vaccination 8?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 8.
Medication or Vaccination 9
Type to begin searching
Was there any information you were not able to include for medication or vaccination 9?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 9.
Medication or Vaccination 10
Type to begin searching
Was there any information you were not able to include for medication or vaccination 10?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 10.
Medication or Vaccination 11
Type to begin searching
Was there any information you were not able to include for medication or vaccination 11?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 11.
Medication or Vaccination 12
Type to begin searching
Was there any information you were not able to include for medication or vaccination 12?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 12.
Medication or Vaccination 13
Type to begin searching
Was there any information you were not able to include for medication or vaccination 13?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 13.
Medication or Vaccination 14
Type to begin searching
Was there any information you were not able to include for medication or vaccination 14?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 14.
Medication or Vaccination 15
Type to begin searching
Was there any information you were not able to include for medication or vaccination 15?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 15.
Medication or Vaccination 16
Type to begin searching
Was there any information you were not able to include for medication or vaccination 16?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 16.
Medication or Vaccination 17
Type to begin searching
Was there any information you were not able to include for medication or vaccination 17?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 17.
Medication or Vaccination 18
Type to begin searching
Was there any information you were not able to include for medication or vaccination 18?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 18.
Medication or Vaccination 19
Type to begin searching
Was there any information you were not able to include for medication or vaccination 19?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 19.
Medication or Vaccination 20
Type to begin searching
Was there any information you were not able to include for medication or vaccination 20?
* must provide value
Yes
No
Please specify any additional information you would like to note for medication or vaccination 20.
Were you unable to enter any medications?
* must provide value
Yes
No
Please specify any medications that could not be entered.
Was dietary data collected from the study participant?
* must provide value
Yes
No
Do you follow a specific diet?
None
Vegetarian diet
Vegan diet
Ketogenic diet
Low-carbohydrate diet
Low-fat diet
Low-cholesterol diet
DASH diet
Mediterranean diet
Intermittent fasting
Other
Don't Know
Please specify your other diet:
Instructions for Interviewer:
Fill in the food groups based on the information recorded above. For food groups not mentioned, ask if any food item from the group was consumed.
Yes
No
Don't Know
Examples: corn/maize, rice, wheat, sorghum, millet or any other grains or foods made from these (e.g. bread, noodles, porridge or other grain products)
2. Vitamin A rich vegetables and tubers
Yes
No
Don't Know
Examples: pumpkin, carrots, squash, or sweet potatoes that are orange inside + other locally available vitamin-A rich vegetables (e.g. red sweet pepper)
3. White tubers and roots
Yes
No
Don't Know
Examples: white potatoes, white yams, white cassava, or other foods made from roots
4. Dark green leafy vegetables
Yes
No
Don't Know
Examples: dark green/leafy vegetables, including wild ones + locally available vitamin-A rich leaves such as amaranth, cassava leaves, kale, spinach etc.
Yes
No
Don't Know
Examples: other vegetables (e.g. tomato, onion, eggplant), including wild vegetables
Yes
No
Don't Know
Examples: ripe mangoes, cantaloupe, apricots (fresh or dried), ripe papaya, dried peaches + other locally available vitamin A-rich fruits
Yes
No
Don't Know
Examples: other fruits, including wild fruits
8. Organ meat (iron-rich)
Yes
No
Don't Know
Examples: liver, kidney, heart or other organ meats or blood-based foods
Yes
No
Don't Know
Examples: beef, pork, lamb, goat, rabbit, wild game, chicken, duck, or other birds
Yes
No
Don't Know
Examples: chicken, duck, guinea hen or any other egg
Yes
No
Don't Know
Examples: fresh or dried fish or shellfish
12. Legumes, nuts, and seeds
Yes
No
Don't Know
Examples: beans, peas, lentils, nuts, seeds or foods made from these (e.g. hummus, peanut butter)
13. Milk and milk products
Yes
No
Don't Know
Examples: milk, cheese, yogurt or other milk products
Yes
No
Don't Know
Examples: oil, fats or butter added to food or used for cooking
Yes
No
Don't Know
Examples: sugar, honey, sweetened soda or sugary foods such as chocolates, candies, cookies and cakes
16. Spices and other condiments
Yes
No
Don't Know
Examples: spices(black pepper, salt), condiments (soy sauce, hot sauce), coffee, tea. alcoholic beverages OR local examples
Did you eat anything (meal or snack) outside the house yesterday?
Yes
No
Don't Know
The dietary diversity score is calculated by counting the number of different food groups consumed (Yes/No) during the 24-hour period.
View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation Dietary Diversity Score *Note: This will be directly calculated in REDCap during data entry
View equation Was physical activity data collected from the study participant?
* must provide value
Yes
No
1a. During the last 7 days, on how many days did the study participant do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?only those physical activities done for at least 10 minutes at a time.
1b. How much time in total (in minutes) did the study participant usually spend on one of those days doing vigorous physical activities?
2a. Think only about those physical activities done for at least 10 minutes at a time. During the last 7 days, on how many days did the study participant do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.
2b. How much time in total (in minutes) did the study participant usually spend on one of those days doing moderate physical activities?
3a. During the last 7 days, on how many days did the study participant walk for at least 10 minutes at a time? This includes walking at work and at home, walking to travel from place to place, and any other walking done solely for recreation, sport, exercise or leisure.
3b. How much time in total (in minutes) did the study participant usually spend walking on one of those days?
The last question is about the time spent sitting on weekdays while at work, at home, while doing course work and during leisure time. This includes time spent sitting at a desk, visiting friends, reading traveling on a bus or sitting or lying down to watch television.
4. During the last 7 days, how much time in total (in minutes) did the study participant usually spend sitting on a week day ?
MET Minutes - Vigorous Activity
View equation MET Minutes - Moderate Activity
View equation View equation View equation IPAQ Scoring a. Vigorous activity on at least 3 days (minimum of 1500 MET minutes per week) b. 7 or more days of any combination of walking, moderate intensity or vigorous intensity activities achieving a minimum total physical activity of at least 3000 MET minutes a week a. 3 or more days of vigorous intensity activity and/or walking of at least 30 minutes per day b. 5 or more days of moderate intensity activity and/or walking of at least 30 minutes per day c. 5 or more days of any combination of walking, moderate intensity or vigorous intensity activities achieving a minimum total physical activity of at least 600 MET minutes a week. a. Do not meet criteria for moderate or high activity
High Physical Activity
Moderate Physical Activity
Low Physical Activity
Was data on substance use collected from the study participant?
* must provide value
Yes
No
1. Has the study participant ever smoked?
No (skip to next section)
Yes
2. Does the study participant currently smoke?
No, former smoker
Yes
3. On average, how many packs of cigarettes does the study participant smoke per day? If a former smoker, how many packs of cigarettes did the study participant smoke per day?
4. For how many years has the study participant smoked in total?
5. What is the participant's lifetime tobacco exposure (pack years)? Assume that one pack is 20 cigarettes. *Note: this will be directly calculated in REDCap during data entry
View equation In the past 6 months, has the study participant used any of the following substances?
Yes
No
Not specified
N/A
aka Malt Liquor, Beer, Vodka, etc.
If yes, with what frequency has the participant consumed alcohol?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Weed, Pot, Grass, Gas, 420, Kush, Purp, Blunt, etc.
If yes, with what frequency has the participant used marijuana?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Coke, Snow, Freebase, White Girl, Bump, etc.
If yes, with what frequency has the participant used cocaine?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
e.g., Rock
If yes, with what frequency has the participant used crack?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Molly, MDMA, E, X, Beans, etc.
If yes, with what frequency has the participant used ecstasy?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Meth, Crystal, Crank, Tina, etc.
If yes, with what frequency has the participant used methamphetamines?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka PCP, LSD, Acid, Mushrooms, etc.
If yes, with what frequency has the participant used hallucinogens?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Smack, Junk, Black Tar, China White, etc.
If yes, with what frequency has the participant used heroin?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka G
If yes, with what frequency has the participant used GHB?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
10. Opiates or Painkillers
Yes
No
Not specified
N/A
aka Oxy, Percocet, Vicodin, etc.
If yes, with what frequency has the participant used opiates or painkillers?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Adderall, Ritalin, Dexedrine, etc.
If yes, with what frequency has the participant used prescription uppers?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Ativan, Valium, Xanax, Ambien, etc.
If yes, with what frequency has the participant used prescription downers?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Excedrin
If yes, with what frequency has the participant used aspirin?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Syrup
If yes, with what frequency has the participant used sizzurp?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Potpourri, Spice
If yes, with what frequency has the participant used synthetic pot?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
If yes, with what frequency has the participant used spray inhalants?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Rush, Head Cleaner
If yes, with what frequency has the participant used poppers?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Special K
If yes, with what frequency has the participant used ketamine?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Yes
No
Not specified
N/A
aka Heroin and Cocaine together
If yes, with what frequency has the participant used speedballs?
Less than once a month
Once a month
More than once a month
Once a week
More than once a week
Once a day
More than once a day
Did the study participant receive a transplant?
* must provide value
Yes
No
The survey is complete, thank you!
Date of Transplant (YYYY-MM-DD)
Today Y-M-D
Single Organ
Multiple Organs
Type of Multiple Organ Transplant
Heart-Lung
Liver-Kidney
Kidney-Pancreas
Other
Please specify other Multiple Organ Transplant
Type of Single Organ Transplant
Heart
Lung - Single
Lung - Bilateral
Liver - Deceased Donor
Liver - Living Donor
Pancreas
Kidney - Deceased Donor, Single
Kidney - Deceased Donor, En-Bloc
Kidney - Living, Related
Kidney - Living, Unrelated
Intestinal
Vascular Composite Allograft
Type A
Type B
Type O
Type AB
Don't Know
Negative
Positive
Don't know/not done
Donor Hepatitis B surface antigen
Donor Hepatitis B surface antibody
Donor Hepatitis B core antibody
Donor Hepatitis C antibody
Previous history of transplant?
Yes
No
Don't Know
Primary diagnosis for transplant (primary cause of organ failure)
Type A
Type B
Type O
Type AB
Don't Know
Negative
Positive
Don't Know
Recipient Hepatitis B surface antigen
Recipient Hepatitis B surface antibody
Recipient Hepatitis B core antibody
Recipient Hepatitis C antibody
Was patient sensitized at the time of transplantation (defined as cPRA>20%)?
Yes
No
Unknown
Methylprednisolone
Basiliximab
Anti-thymocyte globulin
Alemtuzumab
Maintenance (at time of hospital discharge)
Cyclosporine
Tacrolimus
Rapamycin/sirolimus
Everolimus
Mycophenolate
Prednisone
Belatacept
Other
Please specify other maintenance
Rituxumab
Bortezomib
Plasmaphoresis
Other
Please specify other desensitization
Did the patient ever have an episode of allograft rejection?
Yes
No
If yes, date of rejection:
Today Y-M-D
Acute Cellular Rejection
Antibody Mediated rejection
Acute Cellular Rejection - additional notes
Antibody Mediated Rejection - additional notes
