Section 1 | Metadataspec |
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| Order | Question Text | Prompt | Case Report Form Completion Instructions | Type | Collection Variable | Tabulation Target | Mapping Instructions | Controlled Terminology CodeList Name | Permissible Values | Pre-Populated Value |
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| 1 | What is the subject's year of birth? | Birth Date | Record the subject's year of birth (e.g., YYYY, a 4-digit year). |
| BRTHDTC | BRTHDAT |
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| | 2 | What is the sex of the subject? | Sex | Record the appropriate sex (e.g., Female, Male). |
| SEX | SEX |
| (SEX) | Male; Female; Unknown; Undifferentiated |
| | 3 | Do you consider yourself Hispanic/Latino or not Hispanic/Latino? | Ethnicity | Record the participants self-report ethnicity, |
| ETHNIC | ETHNIC |
| (ETHNIC) | Hispanic or Latino; Not Hispanic or Latino; Not Reported |
| | 4 | What is the ethnicity of the subject? (More than 1 choice is acceptable.) | Ethnicity | For a subject who self-reported ethnicity as Hispanic or Latino, Select each value that applies to the subject. |
| CETHNIC01-CETHNIC08 | SUPPDM.QVAL | SUPPDM.QVAL where SUPPDM.QNAM = ETHNIC(n) and SUPPDM.QLABEL = Collected Ethnicity (n) | (ETHNICC) | CENTRAL AMERICAN ; CUBAN AMERICAN; LATIN AMERICAN; MEXICAN; MEXICAN AMERICAN;PUERTO RICAN;SOUTH AMERICAN ; SPANISH
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| | 5 | Which of the following racial designations best describes you? (More than 1 choice is acceptable.) | Race | Record the participant self-report race, |
| CRACE1-CRACE6 | SUPPDM.QVAL | SUPPDM.QVAL where SUPPDM.QNAM = ETHNIC(n) and SUPPDM.QLABEL = Collected Ethnicity (n) | (RACE) | AMERICAN INDIAN OR ALASKA NATIVE;ASIAN;BLACK OR AFRICAN AMERICAN;NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER; WHITE;NOT REPORTED;UNKNOWN |
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Section 2: If the study participant answered: ASIAN ASIAN or "BLACK OR AFRICAN AMERICAN. | Metadataspec |
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| Order | Question Text | Prompt | Case Report Form Completion Instructions | Type | Collection Variable | Tabulation Target | Mapping Instructions | Controlled Terminology CodeList Name | Permissible Values | Pre-Populated Value |
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| 11 | Which of the following racial designations best describes you? (More than 1 choice is acceptable.) | Race | if the subject answered "ASIAN" Select each value that applies. | Text | CRACE05-CRACE10 | SUPPDM.QVAL | For each value that applies, SUPPDM.QVAL where SUPPDM.QNAM ="CRACEn" and SUPPDM.QLABEL = "Collected Race n" where n is the choice value. |
| ASIAN AMERICAN; ASIAN INDIAN; BANGLADESHI; CHINESE; JAPANESE; KOREAN;
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| | 12 | Which of the following racial designations best describes you? (More than 1 choice is acceptable.) | Race | if the subject answered "BLACK OR AFRICAN AMERICAN".Select each value that applies. | Text | CRACE011-CRACE17 | SUPPDM.QVAL | For each value that applies, SUPPDM.QVAL where SUPPDM.QNAM ="CRACEn" and SUPPDM.QLABEL = "Collected Race n" where n is the choice value. |
| AFRICAN; AFRICAN AMERICAN; AFRICAN CARIBBEAN; BAHAMIAN; BARBADIAN; BLACK; BLACK CENTRAL AMERICAN; |
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If the study participant answered: BLACK OR AFRICAN AMERICAN | Metadataspec |
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