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OCR for page 89
APPEND I X E
NATIONAL RESEARCH COUNCIL
COMMISSION ON LIFE SCIENCES
2101 Constitution Avenue Washington, D. C. 20418
MEDICAL FOLLOW-UP AGENCY
L
EXHIBIT A
OFFICE LOCATION:
JOSEPH HENRY BUILDIIVG
21ST STREET AND
rENNSYLVAN 1^ AVENUE, N. W.
(202) 334-2825
Dear Sir:
The Medical Follow-up Agency of the National Academy of Sciences-National Research Council (a
private, nongovernment research organization) is making a survey of the health status of men such as yourself
who participated in studies conducted by the Army at the Aberdeen Proving Ground, Edgewood, Maryland,
between 1955 and 1 97S.
To do the survey, we need accurate information that only you and the other participants can provide.
Although you are under no formal obligation to answer our questions, we very much hope that you will
complete and return the attached questionnaire.
You need not sign your questionnaire; the recorded study number will suffice to identify your reply.
Although this study was initially suggested by the Congress, it is being sponsored by the Army in cooperation
with the Veterans Administration. All personal information will be kept confidential. Your name and reply
will not be made available to anyone outside of the Medical Follow-up Agency, and our report will deal with
groups of men rather than with individuals.
If you wish to know the outcome of this study when it is completed, please check the appropriate box
in the questionnaire.
When you have completed the accompanying questionnaire, please return it to me at the Medical FolIow-
up Agency. An addressed, postage-paid envelope is provided for your convenience.
Your cooperation is genuinely appreciated. Many thanks.
Sincerely,
~~'
Robert J. Keehn
Study Supervisor
RJK/mb
Enclosure
89
Thr National Research Council ~ the principal operahng agency of the Nahona! Academy of Sciences anal the National Acaa?emy of Eng~necnng
to serve government ant other organizations
OCR for page 90
OMB No. 0702-0045
Expiration Date 12/31/84
HEALTH QUESTIONNAIRE
O Check this box if you wish to be informed of the results of this study.
1. Rat is your date of birth?
(Month) (Day) (Year)
2. What was your Army service number (if you remember it)?
3. How much schooling have you completed; Check one answer.
OGrade School
Tess than 6 years)
1
- Completed High School
(12 years)
Grade School
(6, 7, or 8 years)
College
(13-16 years)
4. How would you rate your overt health? Check one answer.
Excellent O Good O Fair ~ Poor
1 2 3 ~
-
5. a. What is your present mantal status? (check one)
~ High School, Incomplete
LJ (9, 10, or l l years)
~ Graduate School
LJ (More than 16 years)
O Marned ~ Divorced :3 Separated ~ Widowed ~ Never mamed
b. How many times have you been married?
c. In what year were you married for the first time? (year)
6. Please give the following inflation for each job you have had (including self-employment) since separation from active
military senace (record in order started):
Date of separation Cal m
Month Year
. . .
Date Date
Ota~dteerd I t~rn;j' b? l began job . | left job | What did you do? (des ribe work)
Month Year Month Year
I O 1-time 1 | |
~ 1 P t-tirne | m ~ l | m m |
Tom an Im m
3 ~ U-tirn | m ~ I | m m |
_90
OCR for page 91
I °tardted | Full- o part- | began job | left fob | What did you do? (desk ribe work)
Month Year Month Year
~ O F~ll-time
4th | 0 Pa t-ti~ne | ~ ~ ~ | ~ m |
1 Flit. e 1 1 1
5th [1 Pa t tilne ~ CE ~ ~ m m
~0 ~.rt:t~n:~ m =~ m m ~
If you have more than six jobs to report, use space at end of questionnaire.
7. which of He following statements best describes your present living arrangements? Check one statement.
O Inning with wife (room mate)
1
a living with parents (brother, sister)
2
O living with other adult(s)?
3
a IN alone
4
8. Please give the following information for children you fathered who were alive at birth (answer starting with the
fist child loom):
.
Order Sex Date born, Does this child have any physical or Is child
of Mo. Yr. mental defects? (check, and if any, descnbe) now living?
~ nale | m ~ ~ O [1 Mental [:1 No
e I ys~c
~ mc~ ~ ~
3rd ~ q M m ~ ~ O No O Mental q Yes
I ~ male ~ l ~ O Physical O No
Ape | ~ Cog: I I [1 Physical
9 1
OCR for page 92
Sex
Order
of
5th []
6th ~3
Date born,
Lo. Yr.
Does this child have any physical or
mental defects? (check, and if any, describe)
m
[1 ~ Mental
~ Physical
a O Mental
_ 1 t1 Physical
If you have more than six children to report, use space at the end of questionnaire.
m
9. Hive you ever had a health problem a health professional (doctor, nurse, etc.) said was caused by exposure to toxic or
poisonous substances?
ONO
1
Is child
now living?
O Yes
O No
O Yes
1
O No
2
O Yes (If Yes, name substancets), describe the problem,
~ tell when and how it was treated, and the result)
10. a. Have you smoked a total of 100 or more cigarettes (5 packs) in your entire life?
No (go to question 11)
C] Yes
b. Have you ever smoked tobacco in any form regularly (daily, more than occasional smoking)?
:] No (go to question 1 l) [A Yes
~ 2
c. At what age did you start regular smoking?
d. During the past month, how much did you smoke on a typical day? (please record your daily consumption for each form
of tobacco):
Cigarettes, number of packs daily
Cigars, number daily
A. Did you ever stop smoking for more than one year? ~1 No
If yes, for how many years, total'
11. a. Dunog the past year what was your daily consumption of alcohol?
~1 None ~
0 1
Pipes, number of pipefuls daily
:1 I no longer smoke.
000
O Yes
, Some (for each beverage listed below, circle your usual number of drinks per day)
Beer less than 1 1-2 3-4 5 or more drinks per day
drinks per day
Wine less than 1 1-2 3-4 S or~more
Whiskey
or tether
hardliquor less than 1 1-2 3-4 5 or more drinks per day
-92-
OCR for page 93
)
11. b. Have you ever been treated for alcoholism or for any health problem due to dnnking?
~ No ~ Yes (If Yes, explain)
t 2
12. How many times EVER have you used or been given each of the following substances? Circle one answer,
A, B. C, D, or E, for each substance.
1-9 10-99 100-999 1000 or more
Never times times times times
Substance
Amphetamines or other stimulants
(speed, SIP, uppers, etc.) A B C D E
Barbiturates or other depressants
(barbs, downers, Quaalude, ludes,
sopor, etc.) A B C D E
Cocaine Dolce) A B C D E
Heroin (H. horse, smack) A B C O
E
ISD (acid) A B C D E
Marijuana (grass, hashish, hemp,
pot) A B C D E
Phencyclidine(PCP, angel dust) A B C D E
Other narcotics, opiates (opium,
morphine, codeine, methadone,
Demerol, Darvon, etc.)
A B C D
Tranquilizers (Miltown, Iibrium,
Valium, Thorazine,etc.) A B C D
13. a. During the past five years have you had medical care for any disease or illness?
No
~ Yes (If Yes, state nature of illness)-
b. Dunng the past five years have you been admitted to a hospital for more than an overnight stay?
O No {] Yes (If Yes, state nature of illness)
1
14. During the past month, did an illness or injury keep you us bed for all or most of a day?
~ No ~ Yes If Yes, how many days were you kept in bed?
1 2
What was the matter?
93
OCR for page 94
15. a. Answer each of the six endings to this question. Does any impairment or health problem-
1) keep you from working at a job or business?
2) limit the ldod or amount of work you can do?
3) keep you from doing any household chores at all?
4) limit the kind or amount of household chores you can do?
5) cause you to need the help of othe.r persons with your
personal care needs, such as eating, bathing, dressing,
getting around the home?
6) cause you to need the help of other persons in handling
your routine needs, such as everyday household chores,
doing necessary business, shopping, getting around for
other purposes?
O No O Yes
1 2
O No [71 Yes
O No O Yes
1 2
O No O Yes
1 2
O No O Yes
1 2
O No O Yes
If you answered '~Yes" to ANY of the six questions in Part a above, continue by answering
Parts b and c, below. If all six answers are "No", skip Parts b and c.
b. In what ways are your activities [united? Describe
c. What condition would you say is the MAIN cause of this limitation? Snecif~
May we phone you for further details?
Phone number (include area code)
If you need additional space to complete your reply to any question, or wish to make any additional comments, please attach
extra pages as needed. (Please indicate question number of responses being continued)
94
OCR for page 95
APPENDIX E
NATIONAL RESEARCH COUNCIL
COMMISSION ON LIFE SCIENCES
2101 Constitution Avenue Washington, D. C. 20418
MEDICAL FOLLOW-UP AGENCY
RJK/mb
Enc. losures
Several weeks ago we wrote to you, copy enclosed, re-
questing information concerning your health. We hope that your
failure to reply was not an oversight and that we shall hear from
you soon.
It is of great importance that we receive your reply. We
hope that you have no past or present health problems to report, but
we cannot know that this is true unless you tell us so. Your conr
tribution to the success of this survey will more than justify the
few minutes of your time required to answer our questions. You have
our assurance that all information you give us will be kept confi-
dential.
Please complete the accompanying questionnaire and return
it to me, using the addressed envelope provided for your con-
venience. No postage is needed. Your cooperation is much
appreciated.
Sincerely,
At'
Robert J. Keehn
Study Supervisor
95
E~IlBIT B
OFFICE LOCATION
JOSEPH HENRY BUltDING
2lST STREET AND
PENNSYLVANIA AVENUE, N W.
(202) 334-2825
Tl'< National - - rek Coastal ~ tee< pincipcl Op~r~hRt ctr~ of the National Academy of Samba cnd the Reboil Ace* - y of EM
In A ~Ot,#~,R~R' limit o,J'r, l~rel'n'2~1tlen,
OCR for page 96
OCR for page 97
APFENDIX E
NATIONAL RESEARCH COUNCIL
COMMISSION ON LIFE SCIENCES
2101 Constitution Avenue Washington, D. C. 20418
MEDICAL FOLLOW-UP AGENCY
This third request for information concerning your health
has been sent by certified mail so that we will Snow that it has
been delivered to yap and that our lack of a reply to the earlier
requests was not due to a wrong addre ss.
You are one of a small group of men whose health is being
studies. You are spec ial in that you alone can provide the informa-
tion we need.
Please take a few minutes of your time to send your
answers to our quest ions. An addre sset, no-postage-required
envelope is enclosed for your convenience.
Should you have any quest ions, please call me co llect,
person-to-person, Monday through Friday, between 8: 30 a.m. and
4:00 p.m., Eastern Time. The number is ~ 202) 334-282S. If you
still decide not to answer our questions, please return the blank
questionnaire. We hope that you will tell us why you are returning
the que stionnaire unanswered.
Sincerely,
Robert J. Keehn
Study Supervisor
RJK/sab
Enc. lo sure
97
EXHIBIT C
OFFICE LOCATION:
JOSEPH HENRY BUILDING
215T STREET AND
PENNSYLVANIA AVENUE, N.W.
(202) 334-2825
rid n~'iO,'~l ' - Gil,`,' Coastal `, tk' p~tnapal operan~tg agency of tJ'l .`JQtto~'al Scow - y of Sc'r~'cr, anti tit, ~taho~tal campy of E,tgtnern~g
to sever goriest - Butt Tot otJtr, org~t~ttzaho~t,
OCR for page 98
~PEt9IX E
MA 24 WASH DC 8/3/84
ZIP
OHATCHEE AL 3627]
EXHIBIT D
YOU WILL SOON RECEIVE A THIRD REQUEST FROM THE
NATIONAL RESEARCH COUNCIL FOR THE ANSWERS TO A FEW QUESTIONS
MAILED TO MEN WHO PARTICIPATED IN THE SERIES OF TESTS CONDUCTED
BY THE ARMY AT EDGEWOOD, MARYLAND. MOST HAVE REPLIED AND HAVE
REQUESTED A SUMMARY OF FINDINGS WHEN THE SURVEY IS COMPLETED. WE
ARE ANXIOUS TO HAVE YOUR PROMPT REPLY.
WHILE MOST HAVE ALREADY RESPONDED, THE SURVEY WILL BE
INCOMPLETE WITHOUT YOUR REPLY. IT IS IMPORTANT THAT EVERY MAN
TAKE PART.
.
-98~
SINCERELY'
ROBERT Jo KEEHN
STUDY SUPERVISOR
OCR for page 99
APPE[IX E
Figure II-4
NATIONAL RESEARCH CUt~IL lSON2ESPONSE SI~-RV~Y
A. IDENTIFYING INFORMATION
RTI PROJECT Ho. 3166
E)~[BIT E
Telephone I~tcrviewer N',n~ber
09999
Doe, John
Box L 23
Hobolcen, NJ 41224
S 11766272
511210
2
3
4
B. SCREENING QUESTIONS
"Eello, may I speak with " Dame on label ?" (If respondent is reached,
proceed to introduction and questionnaire on the back. ~ If respondent is cot reached,
verify the number you dialed. If the comber is correct, ask the person you are talking
with, 'ho you know came on label , or bow I can get in touch with him/her?"
Record any information they volunteer and shack them for their time. If the person does
cot know respondcut, thank there for their time and record the appropriate code.
C. RECORD OF CALLS AND COUNTS
.
ICaL1
No e 0;! te
1
Time
Person
Contacted
Result
Code l
,-
2
3
4
6.
Notes
1
_
1
_ __ ~
.
D. RESULT CODES
TcmPorar~ Codes
1 ~ Ring, No Answer
2 ~ Busy Signal
3 = Unable to toca~ce/Coctact
Respoodcat
4 ~ Respondent Not Available
5 ~ Appointment Made
6 = Breakoff/~rtial.Dats
7 s Language Barrier
8 ~ Other (explain in notes)
Fecal Codes
~-
11 = Interview Comple~e
12 3 Breakoff/Partial Data
13 = Refusal
14- Language Barrier
15 ~ Physically/Hectally Incompetent
16 = Unable to [ocate/Contact
Respondent
17 ~ Other (explain in cotce,
_99_
OCR for page 100
Figure 11-4 (continued)
E. ~N:pPDUCTION -~ Read ouly when named respondent is on the line.
_
Hello, my Dame is and I'm calling from the Research
Brian Institute in N.C. We have been asked by the National Research Council located in
Washington, 0.~. to contact veterans who, from their Accords, were on special assig.=ment
at the Aberdeen Pro`,ing Ground located in Edgewoad, Maryland during their military term.
hay, a few questions that 1 would like to ask you that will only take a few minutes of
your time. However, before I begin, I want to tell you that:
you don't have to answer any questions you don't want to,
Ecu can stop me at any time,
there will be no harm or benefit to you from answering these questions, and
your name and answers will not be revealed to anyocc other than authorized project
staff .
So I would like to begin with the first question.
1. While in the military service, do you recall being sent to the Aberdeen Proving
Ground in Edgewood, Maryland for special duty between lass and 1975?
O Yes O No [STOP]
O Never in service ESIOP]
2. Do you remember receiving a health survey questionnaire in the mail recently from the
National Research Council?
~ Yes O No [STOP]
3. Did you reply as requested?
~ Yes [STOP] ~ No
I want to read a few reasons that might explain why you didn't reply to the
questionnaire. Please tell me all that apply for you. (CIRCLE ALL THAT APPLY)
a. You didn't Chic any health problems to report.
b. You felt the questions were too personal.
c. You were concerned about confidentiality.
I. You felt the questioas.aire was too long.
c. You felt the q,uestio'=aire was too difficult.
f. You didn't participate in the test program rue to your change of mind or
rejection on the part of the military.
c. Are there any other readapt? (SPECIFY)
I want to shack you for your time and Cooperation. Goodbye.
_100-
Representative terms from entire chapter:
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