Document Name and Accession

Document Name: ELIGIBILITY FORM (Nov 2008)
Document Accession: phd007624.1

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ELIGIBILITY FORM (Nov 2008)

Version Date: 11Nov08

RDCRN Protocol #5706   MICEPAP Study

Local ID
Participant ID

Clinical Site and Data Entry
Date of chart review: (dd/mm/yyyy)
Interviewer User ID:
Name of person completing form:
Initial data entry completed using:
Paper case report formOnline data entry form

1. PAP Inclusion Criteria:
Serum collected
YesNo
Method of PAP Diagnosis:
• Lung biopsy diagnostic of PAP
YesNo

  • or

• Bronchoalveolar lavage cytology consistent with PAP
YesNo

  • and

◦ Chest CT consistent with PAP
YesNo

  • or

◦ Serum GM-CSF Ab levels diagnostic of PAP
YesNo

2. Control Subject Inclusion Criteria:
A. Normal Controls:
No history of major medical illness
Not acutely ill at the time of serum collection
B. Disease Controls:
Medical Illness:
C. Dates and Demographics (controls only)
Date serum was collected for this study: (dd/mm/yyyy)
Date serum shipped for evaluation in this study: (dd/mm/yyyy)
Date of birth: (dd/mm/yyyy)
Place of birth:
Country:
Germany
US
Italy
Japan
Other
State:
Provence:
Prefecture:
Unknown
Current Residence:
Country:
Germany
US
Italy
Japan
Other
State:
Provence:
Prefecture:
Unknown
Gender:
MaleFemaleUnknownNot Reported
Race (select one or more):
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Unknown
Ethnicity (select one):
Hispanic, Latino, or Spanish origin
Not Hispanic, Latino, or Spanish origin
Unknown