Patient/Alternate Contact Person(s) Information Instructions Randomization Number Patient/Alternate Contact Person(s) Information Instructions General Instructions This contact information will be used to: determine survival status complete the 6 month follow-up questionnaires. Obtain as much different contact information as you are able to for each of the following: patient person(s) living with the patient persons who do not live with the patient (recommend at least 2 alternate contacts not living with the patient) These data are to be collected once, at consent or baseline.

Patient/Alternate Contact Person(s) Information Form Randomization Number Patient/Alternate Contact Person(s) Information Form Participant contact information: (verify contact information with medical record or alternate) Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Last Name, First Name Middle Name alternate name (i.e. nicknames/alias): □ None #1 _ _ _ _ _ _ _ __ _ _ _ _ _ _ #2 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Email Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Someone who lives with participant: Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Last Name, First Name Middle Name Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Someone with a different address from participant: (obtain complete information for at least 2 people) Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Last Name, First Name Middle Name Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Last Name, First Name Middle Name Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Last Name, First Name Middle Name Home Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Cell Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Work Phone: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Alternate: ( _ _ _ _ ) _ _ _ _ - _ _ _ _ _ _ □ Not Available Relationship to Patient (e.g., father, sister, friend): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _