Document M4zpXVnNZVQyJQaOekNek3k7

r 3 SfM Ammonium Perfluorooctanoate: Cross-Sectional Surveillance in a Community Sample of Clinical Measures of General Health Status Related to a Serum Biomarker of Exposure A Study Protocol Preparedfo r DuPont Haskell Laboratory Newark, Delaware Prepared by The Sapphire Group, Inc. Bethesda, Maryland 2 June 2004 mFT TABLE OF CONTENTS INTRODUCTION........................................................................................................................ 1 BACKGROUND.......................................................................................................................... 1 A. Animal Toxicology............................................................................................. 1 B. Human Epidemiology and Exposure A ssessm ent........................................... 5 OBJECTIVES .............................................................................................................................. 7 STUDY OVERSIGHT, SPONSOR, AND TESTING FACILITIES......................................... 8 REGULATORY COMPLIANCE............................................................................................... 9 STUDY DESIGN ........................................................................................................................ 9 A. Study Overview................................................................................................... 9 B. Community Sample ......................................................................................... 11 C. Sample S iz e ....................................................................................................... 11 D. Random Selection of the Community Sam ple............................................... 15 E. Random Digit Dialing Telephone Survey....................................................... 16 MATERIALS AND METHODS ............................................................................................. 18 A. Test Substance/Exposure of Interest ............................................................. 18 B. Clinical Pathology Evaluation......................................................................... 18 DATA ANALYSES.................................................................................................................... 20 HUMAN SUBJECTS PROTECTION..................................................................................... 21 RECORDS AND SAMPLE STORAGE ................................................................................. 22 PROPOSED STUDY DATES ................................................................................................. 22 REFERENCES .......................................................................................................................... 23 SIGNATURES............................................................................................................................ 28 i 2 June 2004 BFT APPENDICES............................................................................................................................ 29 APPENDIX A COMPUTER-ASSISTED TELEPHONE INTERVIEWING (CA TI)......................................................... 30 APPENDIX B CONSENT FORM .................................................................... 33 APPENDIX C CLINICAL PATHOLOGY COLLECTION PARAMETERS......................................................................... 37 APPENDIX D ELECTROCARDIOGRAPHY (EK G )...................................... 38 APPENDIX E AUDIOMETRIC EXAMINATION.......................................... 39 APPENDIX F VISUAL ACUITY AND TONOMETRY EXAMINATION....................................................................... 40 APPENDIX G COMPREHENSIVE MEDICAL AND WORK HISTORY QUESTIONNAIRE................................................................... 41 APPENDIX H PHYSICAL EXAMINATION AND EVALUATION............. 42 APPENDIX I EXYGEN STANDARD OPERATING PROCEDURE FOR PFOA ANALYSES ......................................................... 43 H:\Project\16001\pool\Community Study\Protocol\Community protocol_final.wpd il 2 June 2004 INTRODUCTION Ammonium perfluorooctanoate (APFO) is a fully fluorinated carboxylic acid used primarily as the ammonium salt to aid in the emulsion polymerization of fluoropolymers. APFO and its salts are soluble in water and readily dissociate to the carboxylate anion, perfluorooctanoate (PFOA). As a result of the presence and biopersistence of PFOA in the blood of humans, the potential health effects of PFOA have been examined in occupational cohorts. Background levels of serum PFOA have also been measured in some general population samples, but no data have been collected in these groups to measure general health status. Epidemiological investigations and medical surveillance of occupationally exposed workers have failed to find any association between PFOA exposure and adverse health effects. However, toxicological findings in animal studies and the slow elimination rate of PFOA observed in humans combine to indicate the desirability of additional surveillance in the general population. This study is being undertaken to provide additional scientifically-credible data that can be used to understand whether or not exposure to PFOA in the community, as measured by serum PFOA levels, is related to adverse health outcomes as measured by standard health screening examinations. DuPont has an external Epidemiology Review Board which will review this protocol, and DuPont will provide technical oversight for the duration of the study. The protocol will also be submitted for review and approval by the University of West Virginia Institutional Review Board (IRB). BACKGROUND The following sections describe studies on PFOA in animals and in humans. A. Anim al Toxicology The liver is a primary target organ for both short-term and chronic effects of PFOA in rats (Griffith & Long, 1980; Olson & Anderssen, 1983; Kennedy, 1985; Pastoor e t a l , 1987) and cynomolgus monkeys (Butenhoff et a l, 2002). The increased liver weight in both species does not appear to be a result of hepatocellular hyperplasia (no increase in nuclear DNA) and has been variously attributed to increases in peroxisomes, endoplasmic reticulum, and mitochondria (Ikeda et a l, 1985; Pastoor et a l, 1987; Butenhoff et a l, 2002; Berthiaume and Wallace, 2002; Biegel e ta l, 2001). Higher doses lead to liver degeneration and necrosis and the appearance in the serum of enzymes reflecting liver damage. 1 2 June 2004 PFOA and other perfluoroalkanoic acids are part of a widening group of substances including plasticizers (phthalate esters), hypolipidemic drugs (clofibrate, nafenopin) and some herbicides (phenoxyacetic acids), solvents (trichloroethylene), and naturally-occurring compounds such as long-chain fatty acids that are known as peroxisome proliferatoractivated receptor alpha (PPARa) agonists (Ikeda et a l, 1985; Just et a l , 1989; Pastoor et a l, 1987; C ooketa l, 1992,1994; Biegel eta/., 1995,2001;Cattleyeia/., 1998). PFOAhas been shown to activate the PPA R a receptor but not the PPARy receptor (Maloney and Waxman, 1999). As with all peroxisome proliferators (PPs), treatment of rodents with PFOA initiates a characteristic sequence of morphological and biochemical events in the liver and, to a lesser extent, the kidney. These events include: marked hepatocellular hypertrophy due to an increase in number and size of peroxisomes, and consequently, a large increase in peroxisomal fatty acid b-oxidation, an increased CYP450-mediated whydroxylation of lauric acid, and a variety of changes in lipid metabolism (Ikeda etal., 1985; Pastoor et a l, 1987; Berthiaume & Wallace, 2002). This response is initiated by the activation of the nuclear hormone receptor, PPARa (Green, 1995; Ashby et a l, 1994; Lake, 1995). There are, however, differences in the effects exerted by different groups of PPs. For example, PFOA did not cause hepatocellular hyperplasia like most other PPs (Pastoor et al., 1987); although the study design did not include looking at early time points, such as 3-21 days. In rats, the hepatocellular response is primarily hypertrophic and is caused by an increase in the number of peroxisomes and proliferation of the smooth endoplasm ic reticulum. In addition, there is evidence for proliferation of mitochondria that may, in part, account for increased liver mass (Butenhoff et a l, 2002; Berthiaume and Wallace, 2002). Peroxisome proliferation induced by PFOA affects fatty acid metabolism and cholesterol synthesis in the liver (Haughom & Spydevold, 1992). Serum cholesterol levels were reduced 50-70% after only 24 hrs in rats fed diets containing 0.02% PFOA, and triglycerols were reduced to about 60% of controls after 7 days. Measurements of selected enzymes in hepatocytes from the PFOA-treated rats showed significant decreases in HMG-CoA reductase, the rate limiting step in cholesterol biosynthesis, and in acyl CoA cholesterol acyltransferase (ACAT),the enzyme responsible for the esterification of cholesterol. It was concluded that the hypolipidemic effect of PFOA is due, in part, to the reduced synthesis and esterification of cholesterol, combined with the enhanced oxidation of fatty acids in the liver (Haughom & Spydevold, 1992). Kudo et al. (1999) confirmed the earlier observation by Pastoor e t a l . i l 987) that PFOA treatment increased the level of triglycerides in the liver and linked this with increases in two triglyceride synthesizing enzymes, glycerol 3phosphotransferase anddiacylglycerol acyltransferase. It also seems possible, however, that the increase in triglycerides in the liver as well as their decrease in the plasma following treatment with PFOA is associated with a decrease in triglyceride secretion from the liver. Clearly, PFOA has the ability to disrupt lipid metabolism by any of several mechanisms that 2 2 June 2004 at the present time are not well understood. The importance of these, if any, in the toxicity of PFOA is not known. A two-year chronic rat bioassay with PFOA indicates a significantly increased incidence of tumors (mainly adenomas) of the liver, testis (Leydigcell) and pancreas (acinar cell) (Biegel et a l, 2001). This is consistent with the fact that PFOA is a PP since, although most attention has been focused on PP-induced liver tumors, both Leydigcell tumors (Cook e ta l, 1999), and pancreatic acinar cell tumors (Reddy & Rao, 1977; Svoboda and Azamoff, 1979) are often observed following chronic exposure of rodents to other PPs. Ohmuraeia/. (1997) showed that the peroxisome proliferator, 4-chloro-6-(2,3-xylidino)-2-pyrimidinylthio-(Nbeta-hydroxyethyl)acetamide (DR931), a potent hepatocarcinogen in rats, was capable of inducing DNA synthesis in pancreatic acinar cells, yet had no effect on ductal or islet cells. Induction of liver, Leydig cell and pancreatic acinar cell tumors is a common finding for PPs (Cook et a l, 1999). In chronic bioassays in rats, Cook et al. (1999) reported that 7 out of 11 PPs induced all three tumor types (Cooker al., 1999), and 10 of the 11 PPs produced liver and Leydig cell tumors (Cook et a l, 1999). The presence and established persistence of PFOA in human tissues, combined with the increased incidence of liver, Leydig cell and pancreatic acinar cell tumors in chronic studies with PFOA in rats, raises questions concerning the potential relevance of tumors observed in chronic studies in rats to potential human health risk. It is generally agreed that liver tumors in rats produced by PPs are unlikely to be relevant to humans (Bentley et a l, 1993; Ashby et a l, 1994; Cattley et al., 1998; Doull et al., 1999). A large number o f humans have been treated for relatively long periods of time with hypolipidemic drugs that are potent PPs in rodents. No significant changes in the peroxisome number or volume occur in humans taking substantial doses of these drugs for extended periods of time (up to 3 years) (Ashby et al., 1994). Therefore, rodents appear to be poor models for human risk assessment with respect to liver effects observed with PPs. The reason for the non-responsiveness of humans to PPs is not yet fully understood; although, research shows differences in amount and expression of PPARa between humans and rodents (Cattley et al., 1998; Palmer et a l, 1998). Experimental evidence for the mechanism of PFOA-induced Leydig cell tumor formation, while not conclusive, tends to support the hypothesis that a sustained increase in estradiol within the testes may be responsible for the increased incidence of Leydig cell tumors in male Sprague Dawley rats (Cook et a l, 1992; Biegel et a l, 1995; Liu et a l, 1996a, 1996b). It was initially thought that PP-induced Leydig cell tumors arose by a mechanism similar to that suggested for liver (Cook et a l, 1992). In the chronic PFOA study, however, there was no evidence that peroxisomes were induced in Leydig cells and no increase in b-oxidation activity above the normal baseline level (about 20 times less than that in liver) (Biegel et al., 2001). Attention has subsequently focused on the role in Leydig cell hyperplasia and 3 2 June 2004 neoplasia of a sustained increase in the level of serum estradiol observed in PFOA treated rats (Liu et a l, 1996a,b; Biegel et a l, 1995,2001). It has been proposed that PPs, including PFOA, increase serum estradiol levels as well as levels in the testis (interstitial fluid) via induction of the enzyme aromatase, a CYP450-mediated enzyme in the liver (Liu et a l, 1996b; Biegel et a l, 1995, 2001; Upham et al., 1998). It is then proposed that the increase in testicular estradiol will modulate growth factors, specifically TGFa, to stimulate cell proliferation in the Leydig cell as it is known to do in other (e.g., mammary) tissues (Liu et al., 1987). The suggested role of elevated estradiol in Leydig cell neoplasia is still uncertain because estrogenic compounds do not induce Leydig cell tumors in rats. It is possible, however, that the failure of estrogenic compounds to cause Leydig cell tumors results from a depression of luteinizing hormone (LH) which has been demonstrated to be the c h ie f driver of such tumors (Biegel et al., 2001). A second mechanism/pathway which has been proposed to be also involved in the formation of PFOA induced Leydig cell tumors is the inhibition of testosterone biosynthesis, which disrupts the hypothalamic-pituitary-thyroid (HPT) axis. In ex vivo studies with PFOA, exposure to PFOA resulted in an inhibition of enzymes critical to the testosterone biosynthetic pathway, which, if occurring in vivo, would subsequently lead to a decrease in circulating testosterone (Biegel et al., 1995). In in vitro studies, 13 PPARa agonists were demonstrated to inhibit testosterone biosynthesis (Liu et al., 1996a). The decrease in testosterone levels results in compensatory increases in LH, increased binding of LH to the LH receptor on Leydig cells, thus resulting in increases in Leydig cell proliferation (Clegg et a l, 1997). In a two-year mechanistic bioassay with PFOA and another PPARa agonist, LH levels were not consistently increased, yet estradiol levels were increased at several time points (Biegel et al., 2001). This is consistent with PFOA inducing circulating estradiol levels, which would attenuate the elevation of LH caused by the inhibition of testosterone biosynthesis. There is, however, evidence indicating a substantial difference in the susceptibility of rats and humans to Leydig cell tumorigenesis. There are numerous pharmaceuticals and chemicals that have been documented to produce Leydig cell tumors in rats and other laboratory animals, but not in humans. These include androgen-receptor antagonists, dopamine agonists, estrogen agonists/antagonists, other PPAR agonists (clofibrate, gemfibrozil), sugars (lactose, lactitol), and nicotine (Clegg et al., 1997). Studies have also indicated that there does not appear to be a difference in the morphology of Leydig cell tumors, whether spontaneous or chemically induced. Since PFOA and other PPs do not increase peroxisome levels in the testis, current ideas regarding the mechanism of PP-induced Leydig cell hyperplasia and neoplasia suggest the involvement of hormone-mediated (estradiol) induction of testicular growth factors (Biegel et a l, 2001). The increased levels of estradiol are thought to result from the induction of a 4 2 June 2004 hepatic cytochrome-P450 (CYP450) mediated aromatase. If this is not part of a pleiotropic PPAR-mediated response, Leydig cell tumorigenicity could involve a distinct hormonemediated mechanism that might be of some relevance to humans. There is, however, evidence indicating a substantial difference in the susceptibility of rats and humans to Leydig cell tumorigenesis. Thus, while the spontaneous incidence of Leydig cell adenomas in ageing Crl:CDfi BR rats ranges from approximately 0-12% and can approach 100% in F344 rats, the rate in humans is reported to be only about 0.4 per million (0.00004%) (Schottenfeld, 1996). It seems highly unlikely that PFOA exposures represent any significant human risk with respect to Leydig cell cancer. There was no evidence of any increase in serum estradiol or testicular cancer in 3M plant workers exposed to PFOA (Olsen, 1998) and in the 6-month PFOA study with cynomolgus monkeys, estradiol levels were not increased (Butenhoff et a l, 2002). Furthermore, there was no increased incidence of testicular or other cancers in humans ingesting high daily doses of fibrates and other rodent PPs for hyperlipidemia (Ashby et a l, 1994). The mechanism by which PFOA and some other PPs induce pancreatic acinar cell tumors is not well understood. It has been hypothesized that it might involve release of cholecystokinin (CCK) in the gut with subsequent stimulation of the acinar cells in the pancreas to secrete pancreatic enzymes into the gut (B iegel et a l , 2001; Herrington & Adrian, 1995). However, it must be concluded that, at the present time, this is a speculative mechanism that is not supported by experimental evidence for PFOA (Biegel et al., 2001; Butenhoff et al., 2002). Even if this is found to be the mechanism operating in rats, its applicability to humans is highly uncertain (Gavin et a l, 1996, 1997; Cattley et a l, 1998; Pandol, 1998). To assess the hypothesis in production workers at 3M, plasma CCK-33 measurements were made by radioimmunoassay during the 1997 medical surveillance of 75 male production workers (Olsen et al., 2002). The results showed a weak negative association between serum PFOA and plasma CCK levels and serum liver enzyme tests showed no indication of cholestasis. There was no increased mortality from pancreatic cancer in these workers (Alexander et a l 2002). B. Human Epidem iology and Exposure Assessment The presence of organic, covalently bound fluorine in human blood was reported by Taves (1968a,b), and Taves et al. (1976) tentatively identified a component of the organic fluorine as PFOA. Following that finding, 3M began monitoring its fluorochemical production workers (Ubel, 1980). Workplace monitoring was originally based on determination of total organofluorine in serum. Speciation and quantitation of PFOA rather than total organofluorine was introduced in 3M's medical monitoring program in the 1990s. 3Mhas also surveyed sera from the general (non-occupational) population. Using high performance liquid chromatography-electrospray tandem mass spectrometry Hansen et a l (2001), Olsen et al. (2002a; 2002b; 2002c) have shown in three U.S. general population 5 2 June 2004 studies serum concentrations of PFOA, regardless of age, averaging approximately 5 parts per billion (ppb) with an upper bound of the 95 th percent tolerance limit approximating 10 to 15 ppb. In another study, Olsen et al. (2003a) examined a total of 30 human donor livers for the presence of PFOA. Almost all donor livers were below the lower limit o f quantitation which ranged between 5.4 to 35.9 ng/g. Of the two donor livers measured above the lower limit of quantitation, one liver had a PFOA concentration of 2.5 ng/g and the other had a mean analysis of 46.9 ng/g. The first published report of serum concentrations in an ammonium perfluorooctanoate (APFO) production workforce (Ubel et al. 1980) indicated a total organic fluorine content of 1 to 71 ppm in 3M employees at an electrochemical fluorination plant in Cottage Grove, MN. The highest serum concentrations were observed in employees with the longest production work history and among a subset of workers whose jobs involved drying and packaging operations. Using gas chromatographic techniques, Ubel et al. reported that 90% of the organic fluorine was PFOA. Additional analyses of total organic fluorine or serum PFOA measurements have been conducted since Ubel etal. in conjunction with medical surveillance of these Cottage Grove production workers (Gilliland, 1992; Gilliland and Mandel 1996; Olsen et al. 1998; 2000; 2003b) and other production workers (Olsen et al. 2003c). Serum PFOA concentrations during the 1990's were comparable to those initially estimated by Ubel et al. (1980) with means (range in parentheses) of 5.0 ppm (0-80 ppm), 6.8 ppm (0.0-114) and 6.4 ppm (0.181 ppm) in 1993,1995 and 1997, respectively (Olsen et al. 2000). Medical surveillance of these Cottage Grove production workers has included a medical questionnaire; measurement of height and weight; pulmonary function testing; and standard biochemical and hematology tests (Ubel etal. 1980; Gilliland etal. 1996; Olsen eta l. 2000; 2003b). Hepatic-and lipid-related blood tests have included alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, gamma glutamyl transferase (GGT), total and direct bilirubin, total cholesterol, high density lipoproteins (HDL), low density lipoproteins (LDL) and triglycerides. Ubel et al. (1980) initially reported that no health problems were associated with exposure to fluorochemicals in this workforce although aggregate analyses were not presented. Others have subsequently not shown abnormal associations between clinical chemistry or hematology findings with either total organic fluorine levels (Gilliland and Mandel 1996) or serum PFOA concentrations (Olsen et al. 2000; 2003b) in this workforce. Although Gilliland and Mandel (1996) suggested that serum total organic fluorine levels might modulate hepatic responses to obesity and alcohol, these interactions were not observed in three subsequent surveillance examinations that analyzed specifically for serum PFOA concentrations (Olsen et al. 2000). 6 2 June 2004 In response to toxicological findings that suggested PFOA might modulate endocrine activity in the rat (Biegel et al. 1995, 2001), serum levels of several hormones (estradiol, free and bound testosterone, FSH, LH, prolactin and TSH) were incorporated in the medical surveillance program of these Cottage Grove workers starting in 1990. Other hormones (dehydroepiandrosterone sulfate, 17 hydroxyprogesterone and sex hormone binding globulin) were added in 1993 and 1995. Gilliland (1992) reported a positive nonlinear association with estradiol and a negative nonlinear association with free or bound testosterone in relation to serum total organic fluorine concentrations. These associations were not confirmed with analyses specific to serum PFOA concentrations although mean estradiol levels were 10 percent greater among employees with the highest serum PFOA concentrations (30ppm) (Olsene/ al. 1998). Possible explanations for the disparity between findings may involve the use of different biomonitoring and hormonal assay methods and possible misclassification of confounding variables, most importantly, body mass index (Olsen et al. 1998). Basedon their data, Olsenei al. (1998) concluded there was reasonable assurance of no significant hormonal changes associated with PFOA at the serum levels measured among these male production employees. Contrary to the relatively rapid rates of elimination reported in laboratory animals (DuPont, 1982; Johnson and Ober, 1980; Butenhoff et al., 2002), PFOA appears to be slowly eliminated in humans (Ubel et al. 1980; Burris et al. 2002). In an interim report, Burris et al. (2002) reported the serum half-life of elimination for PFOA was 4.4 years (S.D. 3.5) in nine retired fluorochemical production employees who had serum concentrations measured over an 18 month time period following cessation of exposure. Initial concentrations ranged from 0.1 to 1.8 parts per million (ppm). Although non-occupational sources of PFOA exposure during the follow-up time period were not accounted for and the half-life study is still in progress, the slow elimination rate observed suggests that humans have the least ability to eliminate PFOA of any species studied. This slow elimination does, however, allow the use of a single measurement to significantly reflect current, recent, past, and chronic/subchronic exposure. This observation, combined with the effects seen in animal studies, warrant further evaluation of the potential health consequences that might result from exposure to PFOA OBJECTIVES The overall objective of this community study is to generate scientifically sound data to further the understanding by DuPont, regulatory agencies, and others of the nature and potential effect of human exposures resulting from PFOA emissions from W ashington Works. 7 2 June 2004 The first objective for this study will be to develop a statistical model describing the variation in the exposure biomarker (serum PFOA), if any, in relation to environmental exposure to PFOA considering traditional epidemiology descriptors, such as age, sex, race, Body Mass Index (BMI), alcohol use, prescription medications, and cigarette smoking status. A second objective will be to model health outcome in terms of the adjusted serum PFOA values. For both the first and second objectives, standard regression methodology will be used to determine which of these potential explanatory variables should be included in the final models. The third objective will be to identify appropriate clinical markers, if any, related to changes in PFOA concentrations in serum to allow proper follow-up through continued surveillance. STUDY OVERSIGHT, SPONSOR, AND TESTING FACILITIES This community survey will be conducted for DuPont by The Sapphire Group, Inc. The following entities have key roles in this endeavor. Study oversight, coordination, and data evaluation: The Sapphire Group. Inc. Bethesda, MD Carol Gevecker Graves, Ph.D., Principal Investigator Physical and clinical examinations and laboratory analyses: Examinetics Kansas City, MO Mary H. Dimitri, Senior Sales Executive (Subcontract to Pacific Toxicology, Los Angeles, CA, for standard laboratory analyses) Serum PFOA level analyses: Exvgen Research State College, PA John Flaherty, Vice President of Operations Cohort interviews and enrollment: Aspen Systems Rockville, MD Marie Pogozelski, Manager, Survey Operations 8 2 June 2004 Random sample selection: Gene ts .Sampling Fort Washington, PA Sponsor: Haskell Laboratory for Health and Environmental Sciences E.I. Du Pont De Nemours and Company Newark, DE Robin C. Leonard, Ph.D., M.A.C.E. REGULATORY COMPLIANCE This study will be conducted according to guidance provided by the American College of Epidemiology Ethics and Standards of Practice Committee which can be accessed at http://www/acepidemiology2.org/policystmts/EthicsGuide.asp. The laboratory analyses provided by the contract laboratories, Examinetics, Pacific Toxicology, and Exygen, will be conducted in accordance with U.S. EPA TSCA (40 CFR part 792) Good Laboratory Practice (GLP) Standards (1989). Appropriate chain of custody procedures for samples and results will be followed (Exygen Research, Standard Operating Procedure). See Appendix I. Additionally, the final laboratory analyses report will be reviewed and audited by experienced GLP auditors. STUDY DESIGN This study will consist of a cross-sectional sample of community residents randomly selected from five water districts to determine the range of values for serum PFOA and various health screening endpoints for people potentially environmentally exposed to PFOA. Each study participant will complete a self-administered health status questionnaire using a questionnaire similar to that used in a study of workers at DuPont s Washington Works facility. Each study participant will receive a physical examination similar to that received by Washington Works employees who participate in the worker study. The examination will be administered in the principal community of each water district. A. Study Overview This cross-sectional survey will use standard epidemiologic and statistical analyses o f several types of clinical data and a biomarker of exposure (serum PFOA) to determine the relationships, if any, between exposure to PFOA and any early clinical signs o f adverse effect in humans. To this end, the study will incorporate data from clinical chemistry and 9 2 June 2004 hematology analyses, as well as clinical parameters customarily utilized in traditional health surveillance examinations, such as chest X-ray, pulmonary function tests, and hearing and vision tests. A broad panel of testing will be conducted that will provide a reasonably extensive snapshot of general health and well-being. These include Chem Screen 25/CBD/Urinalysis, chest Xray, pulmonary function test, EKG, audiometry, and visual acuity tests. Additional specific clinical pathology tests are included that may have more relevance to the overall objectives of the study, based on findings in animal studies and occupational surveillance. These include special tests for lipid profiles, hormone measurements, C-reactive protein, and prostate-specific antigen (Appendix C). Results from the cross-sectional survey will note the prevalence of test values for several health endpoints in community participants. The prevalence of these test values will also be compared across stratification of serum PFOA levels into quartiles. Briefly, the procedures for the community study include these major tasks: Identify service boundaries of the five water districts with detectable PFOA. Select a random sample of telephone numbers of the targeted number of community members in each water district. Preliminary assessment of the sample size needed suggests that approximately 800 residents exposed through drinking water will be a sample size adequate to make meaningful statistical analyses. Communicate via telephone with the randomly selected community residents to inform them of the study and to invite their participation in the study. Coordinate between those selecting the sample and inviting participation and the field team to schedule appointments for physical examination for each participant. Track the review and signing of consent forms and the completion o f selfadministered questionnaires. Perform the physical examination, medical tests, and blood drawing for each selected community participant at a convenient location in each water district. Each participant will be examined once and have blood drawn once for this study. In the event of laboratory accidental loss of specimens, the participant will be notified and asked if he/she is willing to provide an additional specimen. 10 2 June 2004 DFT Following the blood draw, a small bagged snack will be provided to each participant to mitigate the effects of the fast before the participant leaves the examination site. Transfer data electronically to The Sapphire Group for analysis. Analyze data, prepare reports, and communicate study results to participants. Each study participant will receive a printout of his/her individual results. B. Community Sample The five water districts in which PFOA has been detected (and hence which are members of the class) are Lubeck, WV Belpre, OH Little Hocking, OH Tuppers Plains, OH Village of Pomeroy, OH The sample for the community study will be approximately 800 persons chosen randomly from the five water districts in the class. In addition, the study will include some persons who obtain their water from private wells. Adults, defined as persons 18 years of age and older, will be invited to participate. C. Sample Size A power study was conducted to determine the sample sizes needed to have reasonable assurance of finding biologically relevant levels of serum PFOA (J. Green, personal communication). Statistical power considerations are relevant to the proposed statistical analyses since the decision to include or exclude a potential explanatory variable in the proposed regression analyses and the interpretation of the magnitude of a regression coefficient can only be done by taking into account the variance o f the estim ated coefficient. That variance is in turn related to the power of the analysis. The power study consisted of a Monte Carlo computer simulation study and was based on the variance-covariance structure of the 3M study (Olsen et al. 2000, 2003b). While the variability in the community data may differ from that observed in the 3M study, that study constitutes the most reliable information available on variation in serum PFOA levels. 11 2 June 2004 The following table and figures illustrate the results of the power study. They indicate how many subjects are required in any given cohort to detect a difference of a specified percent change based on the population studied by 3M. The sample size required depends on several factors: Size effect one wants to be able to detect Level of confidence one wants to have in detecting that size effect Variability in serum PFOA levels in the population cohort being studied The variability in the proposed study population is presumed to be the same as in the 3M population. Should the variability in the study population be higher, the required sample sizes will increase. As a rule, the objective is to have high confidence (85-95 %) of detecting the size effect deemed important. The results below are divided into gender and age groups, as statistically significant differences were observed in the variation within these populations. For example, the coefficient of variation (CV) in adult males was 0.40, while in adult females the CV was 0.45. The CV observed among elders of either sex was 0.35. Table 1 presents the results of the power study. Figure 1 illustrates the sample sizes required for various power levels (0.75, 0.85, and 0.95) for a CV of 0.25. Figure 2 is a similar illustration for a CV of 0.35, and Figure 3 illustrates sample sizes for a CV of 0.45. An example from the table and figures shows that it is possible to have 95% confidence of detecting a 20% change in serum PFOA levels of adult males or females with 66 subjects. The same size effect can be detected in elders of either gender with only 40 subjects. 12 2 June 2004 Table 1. Sam ple Size (N) Based on Proportion Change To Be D etected, Power D esired, and C oefficient o f Variation in the Cohort Being Sam pled P ro p o rtio n change 0.1 0.2 0.3 0.4 0.5 Power 0.75 0.85 0.95 0.75 0.85 0.95 0.75 0.85 0.95 0.75 0.85 0.95 0.75 0.85 0.95 CV = 0.25 N 38 50 75 11 14 21 5 7 10 3 4 6 3 3 5 CV = 0.35 N 73 97 146 20 27 40 10 13 20 6 8 12 5 6 9 CV = 0.45 N 120 161 242 33 44 66 16 22 32 10 13 20 7 9 14 13 2 June 2004 Figure 1. Sample size graph for CV = 0.25 Figure 2. 14 2 June 2004 Figure 3. Sample size graph for CV = 0.45 In setting the sample size for the community study, a percent change of 10% (i.e., a proportion change of 0.1) was selected along with a power of 85% (0.85). From the table, it can be seen that a sample size of 161 is required to observe this percent change in serum PFOA in adult males or females who exhibit a CV of 0.45. Because there are five water districts (i. e., five sub-cohorts), a sample size of approximately 800 is required (i.e., 160 per water district x 5 water districts = 800). D. Random Selection o f the Community Sample Two methods were considered as the basis for sample selection random selection from water district customer lists or random digit dialing based on Census blocks served by a water district. The telephone survey using random digit dialing was deemed preferable to a random selection based on water district customer lists for several reasons. A name on the utility list may be the owner, but not the occupier, of the residence using the water. The utility lists may not readily identify commercial and other non-residential users. Because negotiations for customer lists may be protracted, obtaining the lists from all five utilities may cause a time burden delaying the initiation of the study. Finally, since it may not be possible to obtain lists from all water districts, the alternate method would have to be used in some water districts. Less bias would be introduced if the same selection method were used in all water districts. 15 2 June 2004 HM FF Random digit dialing (RDD) will be used to select study participants from each water district (Waksberg, 1978; Groves and Kahn, 1980). Assuming a participation ratio o f 10-to1, RDD will be used to screen an initial list of 8,000 eligible residents aged 18 and older, with a residential listing, and living in the five water districts based on Census blocks. This approach will yield an estimated sample of approximately 800 participants balanced by age group and gender. An RDD sample o f residential phone numbers will be obtained from Genesys Sampling Systems, a product of the Marketing System Group (MSG) of Fort Washington, PA. Genesys is recognized as one of the top ten systems for producing RDD samples. Genesys will be provided with the Census blocks for each water district. They will provide RDD blocks of 100 residential phones excluding all businesses, hospitals, schools, prisons, nursing homes, etc. They will provide blocks totaling 8,000 households distributed among the five water districts. Assuming that only one in every 10 persons contacted will agree to participate in the study, this method will generate the desired sample size of approximately 800. Within each water district, the stratified random sample of approximately 160 will be balanced by gender and age groups. Males and females will be sampled approximately equally reflecting the distribution of genders in the community. Within each gender, age groups will be balanced in three broad age categories: 18-44 years, 45-64 years, and 65+ years. The computer-assisted telephone interviewing (CATI) system software will provide daily/weekly counts of sampling quotas incorporating the stratification criteria to ensure balanced recruitment of all three age groups for each gender. (See Appendix A.) E. Random D igit D ialing Telephone Survey Recruitment of the community sample will be subcontracted to A spen System Corporation s Survey Operations Center. They will employ RDD and CATI to accomplish the following tasks: A recruitment call will establish study enrollment eligibility. The phone call will include a brief introduction about the purpose and value of the study to the community and to the individual ( i.e ., free health assessments conducted in a location convenient to their home). Questions will be asked concerning place of occupation and source of water (e.g., public water supply or private well, name of water utility). DuPont employees will be excluded from the community study, as will pregnant women and people on chemotherapy. Telephone calls will be placed between 5 and 9 P.M. EST. 16 2 June 2004 The recruitment screening questionnaire will be programmed for CATI administration offering full telephone interviewing automation and real-time monitoring of study progress as data are collected. The range of capabilities o f the software promote ease of telephone interviewing by simplifying questionnaire programming, call management, quota cell control (i.e., grouping of respondents based on demographic characteristics such as gender and age), calling results, interviewer monitoring, and data reports and delivery. The CATI system offers daily electronic reporting of results to monitor total calls made, quota cell reports of completed interviews by gender and age group, and instantaneous quality control. A pilot study of 100 telephone numbers will be conducted to test the telephone screening questions and participation rates. Based on the results of the pilot test, the recruitment script (introduction and/or questions) may be modified and the recruitment survey retested, as necessary, for clarity. Any persons who agree to participate in the study during this pilot test will be included in the study. Up to four telephone attempts will be made to reach and recruit a randomly selected adult in a household. Upon reaching an adult and after introductory remarks, the telephone interviewer will determine the number of adults living in the household. If there are more than two adults, an adult respondent will be selected randomly based on the nearest birthday strategy (i.e., the adult whose birthday is closest to the date of the interview will be selected for study participation). If the selected adult is eligible after responding to the screening questions (exclude individuals who ever worked for DuPont and verify that their gender and age group quotas remain open for enrollment), their participation in the study will be requested and their home address will be recorded. It is anticipated that for every 10 calls made one person will agree to participate in the community study on the average. Level one of study participation will be based on verbal agreement attained in the telephone recruitment interview. Nightly summaries of eligible respondents who agree to participate will be calculated by the telephone survey vendor to revise the age and gender enrollment quotas within each of the water districts for the next evening s survey. Physical examination appointments will be made at this time and confirmed in writing. 17 2 June 2004 A follow-up letter confirming participation and the date of the examination, the consent form (Appendix B), the self-administered questionnaire (Appendix G), and a pre-paid return envelope will be distributed to each study participant via Federal Express or USPS priority mail. Respondents who do not return the questionnaire, do not make an appointment, and/or do not show up for their physical exam appointment will be telephoned up to three times and urged to participate. A sample in excess of 800 will be recruited to have approximately 800 participants remaining after no-shows are accounted. Level two of assessing the final study participation rates will be calculated weekly, using results from completed self-administered questionnaires and completed physical exams. Study participant rates by age group and gender within each of the water districts will be calculated weekly to adjust subsequent balanced enrollment. MATERIALS AND METHODS Test Substance/Exposure of Interest Test Substance: Ammonium perfluorooctanoate (APFO), assim ilated through environmental exposure Analytical Standard: Exygen (for serum PFOA analyses) and Pacific Toxicology (for all other standard analyses) will provide standard operating procedures that describe their quality control/quality assurance practices. Additional Information: Community residents may have exposure to chemicals other than PFOA. This potential will be addressed in the questionnaire by inquiring about occupation. B. C linical Pathology Evaluation Approximately 30 mL of blood will be drawn into several vacutainer tubes with the appropriate anticoagulants, barriers, preservatives, and other additives as required for the list of analyses listed in Appendix C. This will require the participants to fast for at least 12 hours before the blood collection. In addition to a standard ChemScreen 25/CBD, other serum markers will be measured. 18 2 June 2004 DffiFJ 1. Collection Sites and Samples Sample Volumes: All sample volumes are approximate. (See Appendix C) Collection Parameters: See Appendix C 2. Electrocardiography (EKG) Evaluation Frequency: Once Scope: See Appendix D 3. Chest X-Ray Evaluation Frequency: Once Scope: 14 x 17 PA Chest (full chest x-ray, one view) 4. Audiometrie Examination Frequency: Once Scope: See Appendix E 5. Pulmonary Function Test Evaluation Pulmonary function testing (PFT), or lung function testing, is a method of determining how well the lungs and airways are working. The most common PFT is called spirometry. Each participant will take in as deep a breath as possible, blowing out all of the air as fast and as hard as possible into a tube through which the volume of air is measured. Three attempts are needed, and the best effort is recorded. The results will be recorded as FEV1, FVC, FEV1/FVC%, FEV1% predicted, and FVC%. Frequency: Once Scope: Forced Expiratory Volume 1 (FEV1), Forced Vital Capacity (FVC), FEV1/FVC%, Forced Expiratory Flow (FEF25- 75), Peak Expiratory Flow Rate (PEFR) 19 2 June 2004 BUMF! 6. Visual Acuity Frequency: Once Scope: See Appendix F 7. Questionnaire Frequency: Once Scope: 8. See Appendix G Physical Examination Frequency: Once Scope: See Appendix H DATA ANALYSES The first objective for this study will be to develop a statistical model describing the variation in the exposure biomarker (serum PFOA), if any, in relation to environmental exposure to PFOA considering traditional epidemiology descriptors, such as age, sex, race, Body Mass Index (BMI)1, alcohol use, prescription medications, and cigarette sm oking status. A second objective is to model health outcome in terms of the adjusted serum PFOA values. For both the first and second objectives, standard regression methodology will be used to determine which of these potential explanatory variables should be included in the final models. The third objective will be to identify appropriate clinical markers, if any, related to changes in PFOA concentrations in serum to allow proper follow-up through continued surveillance. In the analyses, each explanatory variable will be broken into a small number of categories. To avoid over-parameterization, a variable that does not contribute significantly to a model will be discarded. 1 BMI will be calculated as weight/ (height2) x 100 using metric units. 20 2 June 2004 Missing values for the age, sex, race, relative body weight or height variables will be entered into the unknown subgroup for that particular variable rather than excluding the subject from the analysis. Assessments of model assumptions will be conducted to ensure that the appropriate statistical procedures/models are used. The data will be displayed with box plots of the distributions and variation for clinical endpoints. It may be necessary to use normalizing, variance stabilizing transformations for these responses. For continuous variables, such as blood pressure, analyses will be based on group m eans, adjusted for any potentially confounding variables. For discrete outcome variables, such as the prevalence of liver disease, analyses will be based on logistic or Poisson regression. In addition, analyses will be performed on the proportion of a group s measurements that fall in the highest or lowest decile. For disease prevalence rates based on sparse data, exact logistic regression may be used. HUMAN SUBJECTS PROTECTION Specific procedures that will be put in place for human subjects protection during this study include, but are not limited to, the following: Detailed consent form from each participant that identifies study purpose, requirements, voluntary nature of participation, right of withdrawal, possible risks, and potential benefits (Appendix B). Coded identification to link biological specimens, exam results, and completed questionnaires. Scheduling of exam appointments to ensure that waiting areas are not crowded. Use of mobile office/laboratory units with sufficient capacity to ensure that only one participant is occupying a test area. Establishment of coded folders or envelopes that will contain each participant's results for archiving. Analytic data files that identify participants only through study subject identification code. Contact information for study personnel so that any problems or questions that should arise for participants can be addressed as quickly as possible. 21 2 June 2004 RECORDS AND SAMPLE STORAGE ,(rf*t*'es,V During the execution of the study and the analysis of data, raw data will be analyzed by The Sapphire Group. These data will be stored in locked file cabinets in a locked office area. Electronic data will be kept on secure servers accessible only by passwords. Access to data with personal identifiers will be limited to select study personnel. Laboratory-specific or site-specific raw data, such as personnel files and equipment records, and specimens (if applicable), raw data, and the final report will be retained at Haskell Laboratory, Newark, DE, or at Iron Mountain Records Management, Wilmington, DE. PROPOSED STUDY DATES Study dates are subject to date of protocol approval and sign-offs. 22 2 June 2004 REFERENCES Alexander, B.H., Olsen, G.W., Burris, J.M., Mandel, J.H., and Mandel, J.S. (2002). Mortality o f employees of an ammonium perfluorooctanoate production facility. Am. J. Ind. Med. (submitted). Ash by, J., Brady, A., Elcombe, C.R., Elliott, B.M,Ishmael, J., Odum, J., Tugwood, J.D., Kettle, S., and Purchase, I.F.H. (1994). Mechanistically-based human hazard assessment of peroxisome proliferator-induced hepatocarcinogenesis. Human Exptl. Toxicol. 13 :(Suppl 2): S 1-S 117. Bentley, P., Calder, I., Elcombe, C., Grasso, P., Stringer, D., and Wiegand, H.-J. (1993). Hepatic peroxisome proliferation in rodents and its signifiaance for humans. Food. Chem. Toxicol. 31 : 857-907. Berthiaume, J. and Wallace, K. B. (2002) Perfluorooctanoate, Perfluorooctane Sulfonate, and N-ethylperfluorooctanesulfonamido ethanol; Peroxisome Proliferation and Mitochondrial Biogenenesis. Toxicol. Lett. 129: 23 - 32. Biegel, L.B., Liu, R.C.M., Hurtt, M.E. and Cook, J.C. (1995). Effects of ammonium perfluorooctanoate on Leydig cell function: In vitro, in vivo, and ex vivo studies. Toxicol. Appl. Pharmacol. 134: 18-25. J.C.Biegel, L.B., Hurtt, M.E., Frame, S.R., O 'Connor, J.C., and Cook, (2001). Mechanisms o f extrahepatic tumor induction by peroxisome proliferators in male CD rats. Toxicol. Sci. 60: 44-55. Breslow, N.E. and Day, N.E. (1987). The Design and Analysis o f Cohort Studies. Methods in Cancer Research, Volume II. Oxford University Press, Oxford. Burris, J.M., Lundberg, J.K., Olsen, G., Simpson, C., Mandel, J. (2002). Interim report No.2, Determination o f serum half-lives o f several fluoroahemicals. St. Paul (MN), 3M Company. US EP A Public Docket AR226. Butenhoff, J., Costa, G., Elcombe, C., Farrar, D., Hansen, K., Iwai, H., Jung, R., Kennedy, G., Lieder, P., Olsen, G. and Thomford, P. (2002). ToXicity o f ammonium perfluorooctanoate (APFO) in male cynomolgus monkeys after oral dosing for six months. Toxicol. Sci. 69: 244-257. C.,Cattley, R.C., DeLuca, J., Elcombe, Fenner-Crisp, P., Lake, B.G., Marsman, D.S., Pastoor, T.A., Popp, J.A., Robinson, D.E., Schwetz, B., Tugwood, J. and Wahli, W. (1998). D o peroxisome proliferating compounds pose a hepatocarcinogenic hazard to humans. Regul. Toxicol. Pharmacol. 27: 47-60. Chemical Manufacturers Association, Epidemiology Resources Information Center, 1991. Clegg, E. D., Cook, J. C , Chapin, R. E., Foster, P., andDaston, G. P. (1997). Leydig cell hyperplasia and adenoma formation: mechanisms and relevance to humans (abstract). Reproductive Toxicology 11:107-121. C.,Cook, J. Murray, S. M., Frame, S. R., and Hurtt, M. E. (1992). Induction o f Leydig cell adenomas by ammonium perfluorooctanoate: A possible endocrine-related mechanism. Toxicol. Appl. Pharmacol. 113: 209-217. C.,C ook, J. Hurtt, M E., Frame, S. R., and Biegel, L. B. (1994). Mechanisms o f extrahepatic tumor induction by peroxisome proliferators in Crl:CDfiBR (CD) rats. Toxicologist 14:301. 23 2 June 2004 Cook, J.C., Klinefelter, G.R., Hardisty, J.F., Sharpe, R.M. and Foster, P.M. (1999). Rodent Leydig cell tumorigenesis: A review o f the physiology, pathology, mechanisms, and relevance to humans. Crit. Rev. Toxicol. 29: 169-261. Doull, J., Cattley, R., Elcombe, E., Lake, B., Swenburg, J., Wilkinson, C., Williams, G., and van Gemert, M. (1999). A cancer risk assessment o f di(2-ethylhexyl)phthalate: application o f the new U .S. EP A Risk Assessment Guidelines. R eglJll. Toxicol. Pharmacol. 29: 327-357. DuPont Haskell Laboratory (1982). Excretion and disposition of 14C-ammonium perfluorooctanoate in male and female rats, mice, hamsters, and rabbits. Unpublished report. Exygen Research. Standard Operating Procedure: Documentation, Accountability, and Sample Chain of Custody Requirements for the Shipping of Serum Samples. Felton J.S. (1992). The In-Plant Occupational Health Service, in Environmental and Occupational Medicine, 2nd ed. Edited by William N. Rom, Little, Brown, and Co., Boston. Gavin, C. E., Martin, N. P., and Schlosser, M. J. (1996). Absence of specific CCK-A binding sites on human pancreatic membranes. Toxicologist 30: 334. Gavin, C. E., Malnoske, J. A., White, J., and Schlosser, M. J. (1997). Species differences in expression o f pancreatic cholecystokinin-A receptors. Toxicologist 36: 1180. Gilliland, F. D. (1992). Fluorocarbons and human health: studies in an occupational cohort. Ph.D. Dissertation, University of Minnesota, Minneapolis, MN. Gilliland, F. D. and Mandel, J. S. (1996). Serum perfluorooctanoic acid and hepatic enzymes, lipoproteins, and cholesterol: a study of occupationally exposed men. Am. J. Ind. Med. 29: 560-568. Green, John (2004). DuPont Haskell Laboratory. Personal communication. Green, S. (1995). PPAR: a mediator o f peroxisome proliferator action. Mutat. Res. 333: 101-109. Griffith, F.D. and Long, J.E. (1980). Animal toxicity studies with ammonium perfluorooctanoate. Am. Ind. Hyg. Assoc. J. 41: 576-583. Groves, R.M. and Kahn, R.L. (1980). Surveys by Telephone: A National Comparison with Personal Interviews. Academic Press, New York. Hansen, K.J., Clemen, L.A., Ellefson, M.E., and Johnson, H.O. (2001). Compound-specific, quantitative characterization of organic fluorochemicals in biological matrices. Environ. Sci. Technol., 35(4):766- 770. Haughom, B. and Spydevold, O. (1992). The mechanism underlying the hypolipemic effect of perfluorooctanoic acid (PFOA), perfluorooctane slJllp h on ic acid (PFOSA) and clofibric acid. Biochem. Biophys. Acta 1128: 65- 72. Herrington, M. K and Adrian, T. E. (1995). On the role of cholecystokinin in pancreatic cancer. Int. J. Pancreatol. 17: 121-138. 24 2 June 2004 Ikeda, T., Aiba, K., Fukuda, K., and Tanaka, M. (1985). The induction o f peroxisome proliferation in rat liver by perfluorinated fatty acids, metabolically inert derivatives o f fatty acids. J. Biochem. 98: 475-482. Johnson, J.D. and Ober, R.E. (1980). Extent and route of excretion and tissue distribution of total carbon-14 in male and female rats after a single IV dose o f FC-143-14C. St. Paul MN: Riker Laboratories, Inc. US EPA Public Docket AR-226. Just, W.W., Gorgas, K., Haiti, F.U., Heinemann, P., Salzer, M. and Schimassek, H. (1989). Biochemical effects and zonal heterogeneity of peroxisome proliferation induced by perfluorocarboxylic acids in rat liver. Hepatology 9: 570-581. Kennedy, G. L., Jr. (1985). Dermal toxicity of ammonium perfluorooctanoate. Toxicol. Appl. Pharmacol. 81: 348-355. Kudo, N., Mizuguchi, H., Yamamoto, A and Kawashima, Y. (1999). Alterations by perfluorooctanoic acid of glycerolipid metabolism in rat liver. Chem.-Biol. Interact. 118: 69-83. Lake, B.G. (1995). Mechanisms o f hepatocarcinogenicity o f peroxisome-proliferating drugs and chemicals. Annu. Rev. Pharmacol. Toxicol. 35: 483-507. C.,Liu, R. C. M., Hahn, and Hurtt, M. E. (1996a).The direct effect of hepatic peroxisome proliferators on rat Leydig cell function in vitro. FlJlndam. Appl. Toxicol. 30: 102-108. C.,Liu, R. C. M., Hurtt, M. E,, Cook, J. and Biegel, L. B. (1996b). Effect o f the peroxisome proliferator, ammonium perfluorooctanoate (APFO), on hepatic aromatase activity in adult male CrkCDBR (CD) rats. Fundam. Appl. Toxicol. 30: 220-228. Liu, S.C., Sanfilippo, B., Perroteau, I., Derynck, E" Salomon, D.S. and Kidwell, W.R. (1987). Expression o f transforming growth factor (TGFa) in differentiated rat mammary tumors: Estrogen induction o f TGFa production. Mol. Endocrinol. 1: 683-692. Maloney, E. K and Waxman, D. J. (1999). Trans-activation o f PPARa and PPARy by structurally diverse environmental chemicals. Toxicol. Appl. Pharmacol. 161: 209-218. Ohmura, T, Katyal, S. L., Locker, J., Ledda-Columbano, G. M., Columbano, A., and Shinozuka, H. (1997). Induction o f cellular DNA synthesis in the pancreas and kidneys of rats by peroxisome proliferators, 9-cis retinoic acid, and 3,3',5-triiodo-L-thyronine. Cancer Res. 57:795-798. Olsen, G. W., Gilliland, F. D., Burle, M. M., Burris, J. M., Mandel, J. S., and Mandel, J. H.(1998). An epidemiologic investigation o f reproductive hormones in men with occupational exposure to perfluorooctanoic acid. J. Occupy. Environ. Med. 40: 614-620. Olsen, G. W., Burris, J. M. , Burle, M. M., and Mandel, J. H (2000). Plasma cholecystokinin and hepatic enzymes, cholesterol and lipoproteins in ammonium perfluorooctanoate production workers. Drug Chem. Toxicol. 23,603-620. Olsen, G.W., Burris, J.M., Lundberg, Hansen, K.J., Mandel, J.H., and Nobel, L.B. (2002a). Identification of fluorochemicals in human sera. I, American Red Cross adult blood donors. ISAPI Public Docket AR-226. 25 2 June 2004 Q Olsen, G.W., Burris, J.M., Lundberg, Hansen, K.J., Mandel, J.H., and Nobel, L.B. (2002b). Identification of fluorochemicals in human sera. II. Elderly participants in the adult changes in thought study, Seattle, Washington. ISAPI Public Docket AR-226. Olsen, G.W., Burris, J.M., Lundberg, Hansen, K.J., Mandel, J.H., and Nobel, L.B. (2002c). Identification o f fluorochemicals in human sera. III. Pediatric participants in a group A Streptococci clinical trial investigation. ISAPI Public Docket AR-226. Olsen, G.W., Hansen, K.J., Stevenson, L.A., Burris, J.M., and Mandel, J.H. (2003a). Human donor liver and serum concentrations o f perfluorooctanesulfonate (PFOS) and other perfluorochemicals. Environ. Sci. Technol. 37:888-891. Olsen, G.W., Butenhoff, J.L., Mandel, J.H. (2003b) Assessment o f lipid, hepatic and thyroid function in relation to an occupational biologic limit value for perfluorooctanoate. US. Environmental Protection Agency docket AR-226, Olsen, G.W., Burris, J.M., Burle, M.M., Mandel, J.H. (2003c). Epidemiological assessment o f worker serum perfluorooctanesulfonate (PFOS) and perfluorooctanoate (PFOA) concentrations and medical surveillance examinations. J Occupy Environ Med 45:260-270. Olson, C.T. and Andersen, M.E. (1983). The acute toxicity of perfluorooctanoic and perfluorodecanoic acids in male rats and effects on tissue fatty acids. Toxicol. Appl. Pharmacol. 70: 362-372. Palmer, C.N.A., Hsu, M. H., Griffin, K.J., Raucy, J.L., and Johnson, E.F. (1998). Peroxisome proliferator activated receptor-a expression in human liver. Mol. Pharmacol. 53: 14-22. Pandol, S. J. (1998). Pancreatic physiology and secretory testing. In Gastrointestinal and Liver Diseases, Vol. 1, Sleisenger, M. and Fordtran, J. S., eds. WB Saunders Co., Philadelphia, pp. 771-782. Pastoor, T. P., Lee, K. P., Perri, M. A., and Gillies, P. J. (1987). Biochemical and morphological studies of ammonium perfluorooctanoate-induced hepatomegaly and peroxisome proliferation. Exp. Mol. Pathol. 47: 98-109. Reddy, J.K. and Rao, M.S. (1977). Malignant tumors in rats fed nafenopin, a hepatic peroxisome proliferator. J. Natl. Cancer Inst. 59: 1645-1650. Schottenfeld, D. (1996). Testicular cancer. In (Schottenfeld, D., Fraumeni, J.F., eds): Cancer Epidemiology and Prevention. New York: Oxford University Press, pp. 1207-1219. Svoboda, D. J. and Azamoff, D. L. (1979). Tumors in male rats fed ethyl chlorophenoxyisobutyrate, a hypolipidemic drug. Cancer Res. 39:3419-3428. Taves, D. (1968a). Evidence that there are two forms o f fluorine in human serum. Nature 217: 1050-1051. Taves, D. (1968b). Electrophoretic mobility o f serum fluoride. Nature 220: 582-583. Taves, D., Guy, W., and Brey, W. (1976). Organic fluorocarbons in human plasma: Prevalence and characterization. In: Biochemistry Involving Carbon-Fluorine Bonds. Filler, R., ed. Washington DC: American Chemical Society, pp 117-134. 26 2 June 2004 Ubel, F.A., Sorenson, S.D., and Roach, D.E. (1980). Health status o f plant workers exposed to fluorochemicals-a preliminary report. Am. Ind. Hyg. Assoc. J. 41: 584-589. Upham, B.L, Deocampo, N.D., Wurl, B., and Trosko, J.E. (1998). Inhibition of gap junctional intercellular communication by perfluorinated fatty acids is dependent on the chain length of the fluorinated tail. Int. J. Cancer 78:491-495. Waksberg J. (1978). Sampling methods for random digit dialing. Journal o f the American Statistical Association 73:40-66. 27 2 June 2004 SIGNATURES Approved by: Robert W. Rickard, Ph.D. Scientific Director Carol Gevecker Graves, Ph.D. Principal Investigator in FINAL PROTOCOL SUBJECT TO EPIDEMIOLOGY REVIEW BOARD AND INSTITUTIONAL REVIEW BOARD APPROVAL 28 2 June 2004 APPENDICES 29 2 June 2004 fa APPENDIX A COMPUTER-ASSISTED TELEPHONE INTERVIEWING (CATI) 30 2 June 2004 Aspen Systems Corporations Survey Operations Center offers the latest in CATI technology. Aspen s boutique telephone center consists of 16 interviewer workstations and a supervisor/monitoring station located within Aspen s corporate headquarters in Rockville, Maryland. Aspen uses CATI software that offers full telephone interviewing automation and real-time monitoring of studies while the data are being collected. The software s range of capabilities promote the ease of telephone interviewing by simplifying questionnaire programming, call management, quota cell (grouping of respondents based on demographic characteristics) control, calling results, interviewer monitoring, and data reports and delivery, including: CATI System. The Survey Operations Center uses the Windows-based CATI software WinCati4.2. The software promotes the efficiency of sample management by controlling the time and day when calls are made based on time zones and/or the results of the previous call. It also controls the number of times a number is attempted, works available sample evenly, and allows for the adjustment and scheduling of callbacks. Rapid Dial (WinCati s autodialing system) further enhances the automation of the interviewing process by increasing interviewer productivity and lowering dialing errors. Interview er Training. Telephone interviewers are provided project-specific instruction and training prior to placing calls. As part of their training, interviewers are given question-by-question instruction manuals as well as background information pertinent to the survey and must actively participate in scripted telephone role-playing. Additional project-specific job aids (e.g., square footage conversion charts, acronym lists, etc.) for collecting data are provided as needed. Q uality Control and Supervision o f Interviewers. Quality control is an integral part of the data collection process at Aspen. It begins with interviewer training and continues throughout the data collection period until the final data file is delivered. From the supervisor/monitoring station, WinCati allows for instantaneous on-screen monitoring of telephone interviews in progress via SuperView. SuperView, coupled with our audio monitoring capabilities, allows supervisors both to see and hear the interviewers work and spot potential problems more readily. Supervisors can then rate interviewers based on their performance. The Remote Monitoring feature allows our clients to listen to calls from their offices. CATI R eports. The WinCati software offers built-in reporting capabilities that permit the overall progress o f the data collection effort to be m onitored on a continual basis. Standard reports showing the current status of the sample 31 2 June 2004 database such as the distribution of records by number of call attempts, by time zone, by quota cells, by callback time, and by most recent disposition can be generated at any time. Quota cell reports, which show the number of completed interviews in relation to pre-set goals for respondents with specified characteristics, can also be run. The reporting system even monitors interviewer productivity by reporting interviewer log-on hours and completed interviews per hour. In addition to printing the reports, they can be downloaded as Excel spreadsheets and sent electronically to the client s desktop for viewing. Data D elivery. At the completion of the telephone data collection period, a clean survey data file in ASCII, Excel, Access, SPSS, or SAS can be created on a read only CD and/or delivered via a secured Internet account established for Aspen clients only. Additional features of WinCati allow the coding of answers to openended questions and the automatic generation of documentation for certain types of output files. 32 2 June 2004 APPENDIX B ^ CONSENT FORM 33 2 June 2004 CONSENT TO PARTICIPATE IN PFOA EXPOSURE AND HEALTH RESEARCH PROGRAM C ross-Sectional Surveillance in a Community Sample of C linical M easures of General H ealth Status Related to a Serum Biomarker o f Exposure Introduction: You are being asked to participate in a health surveillance and research program. Your participation is voluntary. This health surveillance is being conducted in community members and parallels a health surveillance being conducted in workers at DuPont s Washington Works. Please ask questions of the site study coordinator if there is anything you do not understand. What is the purpose o f this study? The purpose of the study is to learn whether there is any relationship between general health status and the blood level of PFOA, also known as C-8. General health status will be measured by a physical examination, blood work, pulmonary function tests, EKG, and urinalysis. These tests are similar to the general health exam that is performed by your personal physician. What does this study involve? Your participation in this study requires one physical exam that includes drawing of blood (about 3 tablespoons) for serum level of PFOA, clinical chemistry, and hematology (red and white blood cell counts, hemoglobin, and types of white blood cells). We will also provide urinalysis, pulmonary function tests, chest X-ray, and EKG. A physician will conduct a physical examination. In addition, you will be asked to complete a confidential questionnaire about tobacco and alcohol use and medical and work history. Will the study be affected ifyou do notparticipate? This research study design was chosen carefully to ensure good statistical analysis with good representation of community members across the five water districts making up the class in a class action suit against DuPont. Random sampling of the community is essential so that we have a good cross-section of people using the water in these water districts. The study will be much stronger if the people selected for sampling by the random process all participate. What are the risks involved with being enrolled in this study? The only risk of participating in this study would be the risk of a bruise (hematoma) where the blood is drawn and possible ordinary discomfort associated with drawing blood. Some people feel light-headed and dizzy when doing lung function tests. Rarely, a person will DRAFT 34 20 May 2004 faint. There will be a chair nearby where you could sit down if necessary, and the technicians are trained to monitor you for any feeling of dizziness. Are there any benefitsfrom participating in this study? The benefit of participating in this study is that you may gain important knowledge about your general health with regard to, for example, your cholesterol, blood pressure, and the level of important enzymes that assist with digestion and liver and kidney function. We also hope to learn more about how exposure to PFOA may vary depending on where in the community people live. Other important items you should know: W ithdrawal from the study: You may choose to stop your participation in this study at any time. New information: To the best of our ability, any significant new findings during this research survey will be made known to you. The clinical services provider for this study, Examinetics, will mail a complete report of your results to your home address, or to any other address that you may provide. Your PFOA blood level will be communicated to you by letter from The Sapphire Group. Confidentiality: Every effort will be taken to protect the names of the participants in this study. All analyses will be conducted on files that have had names removed, and the results will be reported as grouped data. No individuals will be identified as such in any of the published results. All data are retained in locked cabinets in offices of the study overseers, The Sapphire Group, Inc., Bethesda, MD. On completion of the study, data will be transferred to locked cabinets in the Epidemiology Group, DuPont Haskell Laboratory, Newark, DE. Electronic data are kept on secure servers in databases that can only be accessed by The Sapphire Group or DuPont Epidemiology staff. However, you need to know that in litigation pending in the Circuit Court of Wood County, West Virginia, styled Jack W. Leach et a l., plaintiffs, vs. E.I. Du Pont De Nemours Co., defendant, civil action No. 01-C-608, attorneys for the parties will have access to the information generated by this study. However, access to such medical information is governed by the terms of a protective order entered by the court in the litigation. Funding: Funding for this study has been provided by E.I. Du Pont De Nemours Co. Number o f participants: We expect about 800 participants to be enrolled in this community study. DRAFT 35 20 May 2004 Who should you call with questions about this study? Questions about this study may be directed to the principal investigator, Dr. Carol Graves, at The Sapphire Group (301-657-8008, ext. 205) during normal business hours. Will you be paid to participate in this study? No. We estimate the monetary value of the physical exam and blood work to be about $500. You may find your personal results helpful as you consider your own health promotion activities. CONSENT I have read the above information about the comparison of health outcomes in the community potentially exposed to PFOA, and I have been given an opportunity to ask questions. I agree to participate in this study, and I have been given a copy of this consent document for my own records. Your name: Your signature: Date: Witness: Date: DRAFT 36 20 May 2004 APPENDIX C CLINICAL PATHOLOGY COLLECTION PARAMETERS This appendix will be identical to that in the protocol for the worker study. DRAFT 37 20 May 2004 APPENDIX D ELECTROCARDIOGRAPHY (EKG) This appendix will be identical to that in the protocol for the worker study. DRAFT 38 20 May 2004 A P P E N D IX E AUDIOMETRIC EXAMINATION This appendix will be identical to that in the protocol for the worker study. DRAFT 39 20 May 2004 APPENDIX F VISUAL ACUITY AND TONOMETRY EXAMINATION This appendix will be identical to that in the protocol for the worker study. APPENDIX G COMPREHENSIVE MEDICAL AND WORK HISTORY QUESTIONNAIRE [Examinetics questionnaire in separate files.] DRAFT 41 20 May 2004 APPENDIX H PHYSICAL EXAMINATION AND EVALUATION [Examinetics physical examination form will be inserted here.] APPENDIX I EXYGEN STANDARD OPERATING PROCEDURE FOR PFOA ANALYSES [Exygen SOP in separate file.] DRAFT 43 20 May 2004 I 7883 it. P nW if T HEALTH EXAMINETICS An Exemplar International Company Confidential General Health Questionnaire INSTRUCTIONS P L E A S E R EA D A N D FO LLO W T H E S E IN STR U C TIO N S C A R E F U L L Y B E FO R E A R R IV IN G FO R YO U R A P P O IN T M E N T 1. A llow at least 3 0 m inutes to fill out this health questionnaire at hom e, before your appointm ent. If you have difficulty with English or understanding the questions, have som eone help you. Bring this com pleted questionnaire with you to your appointm ent. 2 . Record your nam e and other inform ation on page 2 . Unless instructed otherw ise, print your physician's or health professional's com plete nam e, address, zip code and telephone num ber in the appropriate spaces on page 2. 3 . R ead each question carefully. M ark your answer in the oval next to the questions using an ink pen (o r a very dark pencil). C om pletely fill in the appropriate oval, (see exam ple below ). RHUi>r. AN(NKPI N(OPAVfPYOA I'FNfJU nilP lease in answ er choices com pletely R ight W rong CK> W rong <jf> W rong 4 . If you will be having blood drawn, consume no food or liquid (except plain w ater, black coffee, te a [no sw eeteners/cream ers] and necessary m edications) fo r 12 hours before your appointm ent This includes alcohol, soft drinks, chewing gum, candy and breath mints. D IA B E T IC S O M fT T H IS IN S T R U C T IO N . 5 . P lease drink plenty o f w ater so th at laboratory specim ens (blood and /o r urine) m ay be obtained w hile you are on the unit. Fluid replacem ent is also im portant for your kidneys if you are fasting. 6- D o n o t sm o ke for a t least 4 hours before your appointm ent. 7 . If you w e ar prescription eyeglasses, bring them with you. 8 . If you w ear contact lenses (hard, soft, or gas p erm eable) p lease plan to rem ove them fo r the glaucom a (tonom etry) test w hile you are on the unit. Be sure to bring a storage case and w hatever solutions you m ay need. 9 . Do not photocopy, bend, fold, staple or otherwise m utilate this questionnaire. For___ L o c a tio n . D a te ____ T im e ____ O Health Examinetlcs/Examplar International (11/2003) A l Rights Reserved Version 1 - Novem ber 2003 CONFIDENTIAL GENERAL 7883 PLEA SE P R IN T LEG IBLY A N D FILL O U T C O M PLETELY LAST NAM E____________________________________________ _____________ F IR S T NAM E iTIONNAlRE Ml C IT Y AREA CODE AND HOME PHONE NUMBER SO C IA L SEC U R ITY NUM BER n IIIII STATE Z IP CO DE m e - DATE O F B IRTH (M O N TH /D A Y /Y E A R ) ~ I/ / III AGE EMPLOY!EE ID _L L U ..... SEX O m ale o fem ale ri n r YO U R PERSO NAL PH Y SIC IA N 'S O R H EAL'm PRO FESSIO NAL'S FULL NAM E (F IR S T . M l. LA ST! M A ILIN G ADD RESS O F PH Y SIC IA N T~ C IT Y IIIII STATE Z IP CODE AREA CODE AND PHONE NUMBER P LE A S E B E SU R E T H E A B O V E IN FO R M A TIO N IS C O M P L E T E A N D C O R R E C T Consent I u nd erstan d: ( 1) th e p urpo se o f th is te s tin g and /or questionnaire review pro gram is to in d ic a te p o te n tia l h ealth p ro b lem s, if a n y , fo r e valu atio n ; (2 ) It does n o t tak e th e place o f a fu ll exam ination by m y h ealth p ro fe s s io n a l; (3 ) It sho uld n o t in te rru p t any re g u la r care now being co n d u cted .b y m y h e a lth p ro fession aL I a u th o rize th e designated s ta ff to p erfo rm on m e th o se te s ts and m easu rem en ts com prising th e serv ic e , u n less s p e c ific a lly re fu s e d b y me. I have read or have had ex p la in e d to m e and und erstan d th e in s tru c tio n s fo r c o m p le tin g th is q u e stio n n aire. AN re s p o n s es g iven a re co m p le te and accu rate. You are au th o rized to sand m y te s t re s u lts to m e and, w hen a p p lic ab le , to th e h e a lth p ro fe s s io n a l d esig n ated a b o v e . P L E A S E S IG N IN IN K Signature o f participant (or signature o f parent or guardian if participant is under 18 years o f ag e) z O U ENT NUMB!ER____________________ I C L A S S IF IC A T I T TIN G N O IS E EXP YES NO a hrs O O f-AYBQj LNUMBER N O IS E PR O T O N D O BO O MU O PL SE R VIC E YEARS IfiPOL .MffjttW M E M iE R S S N 5567 Page 2 of 12 v neatn txammeucs/fcxemptar international (itAKju!)) All Rights Reserved 9 OOO 9 I W 7883 A ) PERSONAL AND BIOGRAPHICAL Please fill in answer choices completely cx> cgS Right W rong W rong W rong B ) OCCUPATIONAL (continued) Com pared with other people your own age, how do you rate y o u health? E xcellen t.................................................... O Very g o o d ..................................................................................................... O G o o d .............................................................................................................. O F a ir................................................................................................................. O P o o r................................................................................................................ O How is y o u health com pared to last year? Health is better (im proved) In the past y e a r.......................................... O Health is about the sam e (no ch a n g e )................................................... O Health is w o rse............................................................................................ O H ave you ever been rated as high risk o r rejected for life insurance?.................................................................................................. O W hat is y o u primary race or ethnic origin? (Response Optional) Native A m erican............................................................................... O Asian/Asfan A m erican................................................................................ O Black/Afrlcan A m erican ............................................................................. O Hispanic/Latin A m erican............................................................................ O W hite (C aucasian).................................................. O O th e r............................................................................................................... O B ) OCCUPATIONAL W hat tvoe of work do you cu rre n tly do? /m ark one response onM M anufacturing/production.......................................................................... O Transportation equipment o p erato r......................................................... Other equipment o p erato r......................................................................... C raft/tra d e .................................................................................................... C lerical........................................................................................................... M anageriai/adm inistrattve.......................................................................... Sales/m arketing............................................ O O O O O O Professional/technlcal................................................................................. O S en dee........................................................................................................... Other type of work.................................................................. Retired or not w orking.................................................... O O O In the o ast v e e r, did you breathe, a t least w eekly, irritating or toxic gases, vapors, dusts, fum es, or mists a t work? (m ark one response only) No, or toss than once per w e e k ............................................................... O Yes, 1 to 2 days per w e e k ......................................................................... O Yes, 3 to 4 days per w e e k ......................................................................... O Yes, almost constantly............................................................................... O If you w ere exposed to dust, was the dust exposure: Not erqposed.................................................................................................. O M id ................................................................................................................. O M od erate........................................................................................................ O S e v e re ............................................................................................................ O If you w ere exposed to irritating or toxic gases, w as d ie exposure: Not exposed................................................................................................ foWd.................................. ............................................................ ................ M o d e ra te ..................................................................................................... . S e v e re ......................................................................................................... In y o u work, have you perform ed task(s) that have caused pain, soreness or stiffness that interfered with y o u job, hobbies, and/or personal life in any of the following places? (m ark all th at aoolvl F ingers............................................................................... ................ :....... H an d s........................................................................................................... W ris ts ........................................................................................................... A rm s .............................................................................................................. E lbow s.......................................................................................................... Shoulders.................................................................................................... . N e c k .................................................................................................... ......... B a c k ................................................................................... ......................... H ip s ............................................................................................................... L e g s .............................................................................................................. Knees ........................................................................................................... A n kles........................................................................................................... F e e t............................................................................................................... Have you e v e r had daily or w eekly exposure (on y o u skin o r by breathing) to any of the following a t work? | A rsen ic... A s b esto s C adm ium C oal d u s t........ Dust or smoke Is o c y a n a te s ...................................... L e a d ................................................... M ercury............................................. Nickel or chrom ium ........................ Polychlorinated biphenyls (PC B s) Radiation or X -ra y s ....................... . R C F (refractory ceram ic fib e rs )... SSca (foundry or sandblasting).... Solvents or d egreasers.................. T a lc .................................................... Urethane fo a m s .............................. . W elding fum es o r soldering agents W ood d u st........................................... None o f the a b o v e............................. 5567 Page 3 o M 2 B MPiiBhPvaminatirc/k-vemnlarIrrfornofirvtal ftlhtwwV AHDlnMeDaeeruad 0 0 0 0 0 0 !0 0 t0 i 0 0 0 0 0 0 0 0 0 0 0 0 0 0l 0! 0 f0 i 0! 0 ! 0S0 2 1 ": 7883 U Please fill in answer choices completely W * <X> <5 Right W rong W rong W rong HOBBIES Do you have any hobbles o f "Bid* Job* that require you to regutarty u m chem icals, such as solvents, lead, mercury, furniture stripper, paint, insecticides, herbicides, o r chem ical foams? o Do you have any hobbies or 's id e Jobe* that cause you to be exposed to a tot o f dust (woodworking, autobody work, construction, sandblasting, demoMion work, auto m echanics, etc.)? _ D ) FAMILY HISTORY H ave any o f your blood relatives had any o f the following? Sister, Mother Brother, Son or Father Daughter A s th m a ___ ... B irth d e fe c ts . > * C ancer o f the breast O O ...o o o C ancer o f the colon (large Intestine or rectum )___ ___ .... O C ancer o f ihe lun g ......................................................... -- O C ancer o f the prostate............................................................ O o o o C ancer o f uterus, cervix or o varies......... ..... ........................O D epression. . . . . ..... ...... ...... .......---------. . . . .... ...................... O Drinking ptoblemfalcoholiam o o o G lauco m a............................................ .................................... O Hearing loss or deafness before age 50 H eart attack before age 8 0 ------------------ o --o High blood pressure..... ............................ ..... o High cholesterol le v e l..............__ ____ Intestinal polyps (growths) -- ., --o o M # o o o o o o Lym phom a or leukem ia____ __ ___ oo Osteoporosis (thinning o f the bones) o Peripheral vascular disease (very poor circulation).____ O Psychological or mental dteotdar...----- --------------- ......__ O S evere bleedtog tendency (e.g . hem opha, "bleeder") O o o o o S ickle cell anem ia___ .....-- ___ ____________ ........____ O o S tro k e ........... M a lH (W - ...o o Sugar d iab etes........... Tuberculosis (T B ). * oo .... o o O ther cancer (maBgnancy)___ _ O ther m ajor lung problem (s)...... ..o o .... o o CANCER Have vou ever been diagnosed as havlno cancer or other tum or In any of the M ow ing? (m ark s i that apply) a d d e r.... B one__.... Brain. B reast...-------------------- Colon (large Intestine or re c tu n )... G a lb lad d er................... Kidney........... ..................... Leukem ia........................... L iver__________________ aM M aaaasiaaaaaaittaaw M attaai Lung: In t ie past y e a r______ More than a year a g o . W IM atH aM H M 4M H M M na*atlM M Lym phom a.................. ....... aaaaaaaaaaaaaaa*aaaaaaaa an M esotheliom a a a a a a a a a a a a a a a * a a a a a a a a a a a a a a a a a a a a * a a a a a iia a a a a a a a a a a ia a ia a a a a a a P ro state____ __ ..... iaia*aaatM M M ttM taM fM aaH aaM a< S kin ............................. Stom ach................... .. TestkaJer___ ____ .... Uterus, cervix or o varies___ ________ O ther cancer o r tumor not feted above F ) INFECTIOUS DISEASES H a w you had a cflphtheria/tetanus (lockjaw) booster vaccination tn ttl fitttiL liS fiJittU S ? * a a a a * a a a a a a a a a a a a a a aea ee * ea ea ea ea aa * a* a aa ee ea e e e ie a i H a w you bean vaccinated gainst hepatitis?.............. ........................ Haws you had any o f tha fbAowirg condtiont? EnO SpIldU t a a a a a H H M tM a * 4 ff a fM a a M a * a M a a tM H i M ,ti,M a M a a Hepatitis 0 ^3 * a a* a a a * a a * a a .a a a .a a a a a a a a a a a a .a . a a * .a a a a a * a a a a a a a a a a ia a a a M a a a a a M a r p iaaaaaaM aiaa*M aaaaM M iH <aM *aaaaaiaa<aiM aa**aaaaaaaaaaaiM H ataaaaaM M aaslas a a ia a a a a a a a a a aa aa aa aa aa * aa aa aa a a aa aa a* a a a a ia aa aa aa a ai * a aa .aa aa aa aa a M a * a Meningitis aaaaa* a M a aa M aa aa aa aa aa a a a* a aa a* * * a aM aa a* a * a a aa * aa aa aa aa aa aa a a aa .a* a Rheumatic fever; In the past y e a r-- ....--------------------------------- --------------------------M ore than a y e a r a g o __________ >****a a a a a aa a* * a a* a aa aa aa iaa a aa*4 fl Tuberculosis: In the past y e a r aax aaaaa aa # a* a sa< a aa a o a aa aa .aa * aa aa a.* a a a * M a aa a a aa a* a < aa aa * * a* a ai M ore then a year a g o ....--------- ----------------------------------- ------- .... 5567 Page 4 of 12 C H aalth Eamlnaticaxamplw Internaorta (11/2003) AS Right* Reserved 7883 G ' ) HOSPITALIZATION AND SURGICAL Have you been Inthe hoepkel as a p etlert In the p ast y e a r? ..............O Hava vou w i r had a surgical operation on any o f the M ow ing? SW n.......... B rain ....... E y e ............. N o s e .......... E a r............. lilllU llin n H M U M M N IIM M tU .o o o ............................ -- ----------o T h ro at...... Esophagus 1 . . . . . . . . . . . . . . . . . . . . . . . . . . Voice box (taryrsQ------------ --------- Chest in th e past year I I M t M H H H M I M H I M I M I M H I l H m i H M M t M I t I H I N I M M n I H M M M M ora than a year a g o --------------------------------------.....----------------- O Breast rem oval (mastectom y) ......................................... Lung H e a rt Artery, coronary bypass, o r angioplasty (to correct blocked artery or aneurysm ): In the past year aaaMaaiaaMiaaaattaaaaMaHaaaaMatiaHaaMaMaMaaaaaaaaaaaaiaMiwaaaaM ^!aa^ M ore than a year a g o .~ .--------..................-- .......... ......... ......... . O Stom ach.............. .aaaaaasaaaaaaafi a ai o Intestine o r colon ia aaaaaaaaaaaaaai ia a a a a * a H iM a a a a a a a ia a a * a a a aa aa aiiaa o Appendbc... >a*M aaaaaaaaaM M aaaaa(aa<*a4*aM aaaaaaaM ai G aM ad d sr aaaa**aaaiaaaataM M ta<M H aM M aM iaaa**aa*taaH aaataa*aaaiaaa*aaii o o Uver . . . h . . . . . . . . o Kidney' ta a a a ila a a a a M f a a a o Hernia (rupture) o o*C * Section (C aesarean section) iM M H M N ir M > H M a N eeaeaaasaaasasaeaaaee Both ovaries removed: A t age 44 or younger---------- o A t age 4 5 or older iaaaaaaM H iaaaaaaM at*N N aM aa**aatM ia H ysterectom y----------- laaaaaaaaaaaaM taaaaM P ro s ta te -------- aaaaaa aaa aaa aa aa aa aa aaaaa aaa aaa aa aa a aa o o o T e s tic le s ......... aaaaa aaaa a aaaaa aaa aa aa aa aa a aa aa aaaaaa o oRectum (hemorrhoids o r p ie s ) a aa aaaaa aaa aaa a aaa a aa aa aa a a aaaaaaaaaaaaaaaaaaaaaaya Node o B ack___ ......... Varicose veins oa a a a a a a a a ia a a a a a a a a a a a a a a a a a a a a a a a a e a a a a a a a a a a a a aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa## o O ther surgery (please specify) o Never had surgery. aaaaaaaaaaaaaaaaaaaeaaaa Please fill in answer choices completely ^ < 9 <X> <2$ Right W rong W rong W rong H ; MEDICATIONS Are you currently taking prescription medication for any condition? Y es, and I usually take the m edicstlones prescribed----------------- O Yes, end I sometimes take the m ed iatio n as prescribed ---------- O Y es, and I seldom take the medication as prescribed -- ..... -- O NO ......M . . M . . . ..................................^......M............. Have you taken any of the M ow ing medications for more than 10 dava? im ark ail that scoivi Currently Taking In th e Past Year ....Antacids or stomach m ed U n e------------------------------ O .O A n te fa tto {p e tM *\e m o y d M n , e tc .)------------------ . . a O ... oAndcoagularts (blood thkm ere)................................. ArtfioamulsaflL s e iz m medkdne (dilantin, phsnoberbltaL e tc .)r a a a a f a aa aaaaa a aa aaaaa a< ... o Antidapressants / mood elevatore... Asthma, breatNng or lung m edicine. .... o .... o Birth control p is ---- ----------------------- .... o Cholesterol lowering agen ts.............. Hey fever rnodidnes.................... a aa a a a a a eea a a a a a ai O ..... o .... o .... o O o o o o o o o o o Heart m eddne (such as digitals, nitroglycerine. Indaral/propranoM , IsordR/lsosorbide nitrate, e tc .) .a aaa aa aa aa aa aaaaa aaaaa ..... o ..... oH a rta l rem ediesr aa a aa aaaaaaaa a a aaa a aaa aaaa aa aa aaaaaaaaaaaaai H g h blood pressure p a s -------- aaaaa aaa aaa aaaaaaaaaa ..... o Horm one replacem ent therapy aaaaaaa aa aa aa aa aa aa aa aa ae aa ai o ... oIro n ..._______ ______ ________ aaaaaaaaaaaaaaaaaaaa< InsiMn shots tor d ia b e te s........ ..... o Non-prescription pain kMete more than tw ice w eekly (e.0., Anadn, Budarin, A P C s, Tylenol, AdvM, Motrin, Aleve, aspirin, touprofen, acetam inophen, ^ PMs for diab etes............................... -- .......................... O Prescription pain kMete (codeine, morphine, dem eroL Darvocet, Peroodan, e tc .)__ __ ________________O Sedatives or sleeping pMs (barbituratee, nembutaL StC.) ....H......M.............M...M.........M.M.........M,....,. Stimulants (benzedrine, amphetamines, e tc .)............. O Thyroid m s rfld n s .t.a.a.a e s a a s e s e a a s s a a s s s a a e s a a a s s a a a a a a e s a e i TranquMzsre.* aa*aaaaaaaaaaaa< a a a a a a a a a a a aai W eight oontral p H s __________ _____________ o o ...... o O th er horm ones.t e a a a e a e a s a a a e a a a a a a a a a s s e a s a a s s s a a a a s e a a e a O ther prescription m edications. o ... o o o o o o o o o o o o o o o o 5567 suol Page S o t 12 S H5BKExamnatics/ExamblarIntemadcnai MV! A I Riahts Rasarvad boooooo 7883 I ) ALCOHOL USE fP l How m any drinks do you consume on s v trs g i? (Include bottles or cans of beer. cocfctaNs or shots of hard liquor, or glasses o f wine) fmartt one response onhrt N o n e .................. --o 1 to 3 per w eek. 4 to 7 per w eek. 1 -2 perday ...... o o 3 - 4 per d a y ..... 5 - 6 per d a y ..... --o M ore than 6 per d a y ____ ...____ ... W hen you drink alcohol, what is the marimum number o f drinks you consume In one hour? 1or few er per hour______ ______ ..._______ ______ ______ _ O 2p er h o u r________ .TM ..TM ........ .......-- .......... __ O 3 per h ou r................................................... 4 or m ore per hour............................ .......... -- ....................... ......... .... O In the past 6 months, have you felt you should cut down on yore anraong < 1 , In the pest fl months, have people annoyed you by criticizing your In the past 6 months, have you fe ll b ad y o r guMy about your ufinlUny--- * m M < nM w w w n iw in in n N w w > to toe past 6 montos, have you taken a drink first thing upon awakening to get rid o f a hangover o r to steady your nerves (eye o p en er)? ... J 3 MOTOR VEHICLE SAFETY How m any dines In the past year dkl you drive after havtog three or more alcohoLcontalnfng drinks vdtoin 2 hours, or ride wRh a driver who had H is much to drink? 1 to 3 times 4 to 11 tim es. M onthly...___ W e e k ly _____ D a ly _______ >-- -- e s -- O O ~.o .. o -O o On average, how dose to toe speed Im R do you usualy drive? Below or w lhtoS m p h over the Im k ______________ to lOmphoverthefm#.......................... ......... 11 to lS m p h o v e rlh e lm lt-------------------------------------More than 15 mph over toe I n t i __________________ -o -O ~ .o .... o Please fill in answer choices completely cx> Right W rong W rong W rong J MOTOR VEHICLE SAFETY (continued) W hat percentage o f toe me do you w ear a seetbelt o r shodder harness whto driving or riding to a car, truck, or van? Always (100% ) ........................... .. U sualy (51 to 9 9 % )-------------------O ccaskm aly (20 to 5 0 % )-----------Rarely (less than 2 0 % )--------------- K ) TOBACCO USE Do you now or did you ever smoke cigarettes? fmaric one rtsnonna o n M No, I never have............... Y es, I s t* smoke -- -------- I quR 10 o r more years a g o . I q u l 5 to 9 years a g o -------- I toquit 1 4 years a g o ....-- I quR less than a year ago, but not to toe past m onth. I quR to the past m o n th .,.........TM ..... Mark the number of packs o f cigarettes you smoked p ar day in the oast tw o years or toe Ia s i tw o years before oultttoo: (1 pack * 20 o r 25 cigarettes) Less than 1 /2 pack par d a y --------------- -------------------------------------- 1/2 pock par d a y .................. .m.................... ....... 1 pack par d a y .............. ............. 2 o r more packs per d a y ------------ -- .-- ----------------------------------- Do you currently use a rv o f the folowlno tobacco products a t least once a day? P ip es. C ig ars.... ......... ..... Smokeless (snulT, chewing to b a cc o )....... boob boo 5567 Page 6 of 12 M ^ *. 7883 L ) PHYSICAL ACTIVITY IS)A P lease fill in answ er choices com pletely Q cp Right W rong W rong W rong O ") METABOLISM 0 0 0 0 0 0 00 0000 0 0 0 0 0 0 0 0 0 0 00 Com pared with other people your age, how would you describe the am ount o f exercise you get, counting work and leisure activities? Much m ore a c tiv e .......................................................................................... O Som ew hat more a c tiv e ................................................................................ O About a v e ra g e ................................................................................................O Som ew hat less a c tiv e .................................................................................. O Much less a c tiv e .............................................................................................O M edical condition limits my activity............................................................O Have you ever had any of the following? Thyroid problem or diso rd er.......................................... Elevated blood sugar or d ia b e te s ................................ Diabetes only during pregnancy.................................. Childhood (before age 3 0 ) onset d ia b e te s ............... Adult (at age 30 or older) onset d ia b e te s .................. O ther m etabolic p roblem s............................................. Have you had any o f the following in the o ast year? in an average w eek, how many tim es do you engage in vigorous aerobic physical activity? (Aerobic means work that lasts at least 20 minutes without stopping and that is hard enough to m ake you breathe heavier and your heart beat faster.) Unintentional gain o f 10 or m ore pounds.................. Unintentional loss o f 10 or m ore pounds.................. . Less than 1 tim e per w e e k ........................................................................ O 1 to 2 tim es per w e e k ................................................................................... O 3 o r m ore tim es per w e e k ........................................................................... O Have you e v e r had any o f the foliowing? C a ta ra c ts .......................................................................................................... D o you do muscle-strengthening exercises such as vigorous manual labor, push-ups, sit-ups, or weight training three o r m ore tim es per w e e k ? .................................................................................................................... O Do you do stretching and/or warm -up exercises for muscle and joint flexibility three or more tim es per w e e k ? ......................................................O G laucom a........................... ............................................................................ Left eye: blindness o r lost vision................................................................ Right eye: blindness or lost v is io n ............................................................. Have you had any o f the following in the p as t y e a r? Corrective lens prescription has changed m ore than o n c e ................ H ave you had any o f the following in the o ast w a r? Noticed a m ole, wart, o r growth that is getting larger, darker or b leed in g .............................................................................................................. O Sore or swelling that has not healed In the past 2 m o n th s................ O Eczem a o r recurrent ra s h ..............................................................................O Severe skin rash or d erm atitis......................................................................O Any type o f skin rash you feel was related to your w o rk .................... O Itching, dryness, cracking, or peeling and scaling o f the h an d s ........O Burning sensation in the hands, or reddening o f the s k in .....................O Sudden, tem porary loss o f vision ............................................................... Eyesight has becom e worse and you have not seen a health professional concerning th is ................................................................ Vision is blurred or cloudy............................................................................ Frequently irritated, red or bloodshot e y e s ............................................. Burning, tearing or redness o f eyes that occurs only w hile a t w o rk . Have experienced double vision................................................................. Bright colored rings (halos) seen around light b u lb s............................ Any other eye o r vision p ro blem ................................................................ None o f the a b o v e ......................................................................................... Cracking o r bleeding of the skin on your h a n d s .....................................O Cracking o r bleeding o f the skin on your fe e t.......................................... O Do you w ear corrective lenses (eyeglasses, bifocals, o r trifocals)? ... Do you w ear contact len ses? ......................................................................... O ther skin p roblem s........................................................................................O N ) URINARY TRACT H ave you e v e r had any o f the following? Kidney disease or inflam m ation/nephritls................................................. O R enal d ia ly s is ....................................................................................................O How m any hours do you spend daily looking at or working steadily with a com puter m onitor (V D T , Video Tube, C R T, LCD, etc.)? N o n e.................................................................................................................. Less than 1 hour per d a y ............................................................................. 1 to 2 hours per d a y ...................................................................................... 3 to 4 hours per d a y ...................................................................................... 5 to 6 hours per d a y ...................................................................................... H ave you had any o f the following in the o ast y e a r? Blood in your urine.....................................................................O Bladder d is e a s e ............................................................................................... O 7 or more hours per d a y .............................................................................. Do you have any difficulty distinguishing betw een colors? Y es, and this affects my ability to perform my Job............................... Y es, but this does not affect my w o rk ...................................................... N o ...................................................................................................................... 5567 Page 7 of 12 Health ExamineUcs/Exsmplar International (11/2003) All Rights Reserved U& 000000 000 P lease fill in answ er choices com pletely <JP Right W rong W rong W rong | Q ) EARS AND HEARING R ) RESPIRATORY H as your hearing been tested by som eone other than you- current em p lo yer? .............................................................................................................O Have you had any o f the following in the o ast y e a r? CM ore than 2 or 3 sinus Infections (sinusitis).............................................. H ave you been to an ear specialist In the past y e a r? .............................. O H ave you e v e r had any of the following? P erforated (ruptured) eardrum .................................................................... O Frequent (m ore than 1 per year) ear infections after age 6 ............... Q Increased hoarseness o r change in your v o ic e ...................................... G CNoticed that certain chem icals m ake you c o u g h ................................... CUsually have a cough (including smoker's co u g h ).................................. Cough up phlegm (sputum) from the lungs (chest) daily for 3 or more m o n th s ............................................................................................ G E a r d ra in a g e .....................................................................................................O E ar surgery recommended but not p erfo rm ed ........................................ O N oticeable hearing loss in left e a r ......................................... ..... ............... O If yes, is it more than 1/4 cupful o f phlegm (from the lungs d a ily )..... G O ther lung problems, disease, symptoms o r lr^ury in the past year.............................................................................................................. G Noticeable hearing loss in right e a r ............................................................. O H ave you had any o f the following? Hearing that com es and goes (fluctuating hearing lo s s ).................... O A sthm a................................................................................................................ G Sudden o r rapid loss o f h earin g ............. O S evere persistent ringing, buzzing or roaring in the e a rs .................. O Abnormal chest X -ra y ...................................................................................... G Asbestosls.......................................................................................................... G Fam ily or friends te l you that you have a hearing problem .............. O Difficulty understanding speech In a crowded (noisy) ro o m .............. O Listen to loud music a t a dub, at hom e o r with a "boom box*, using a "walkman", or ear phones a t high volume levels for 3 or m ore hours per w e e k .......................................................................... O Hobbies or hom e activities where you are exposed to loud noise (gunfire, lawn mowers, chain saw, gas or electric m o tors)................... O H ave you had any o f the following in one or both ears in the o ast year? Chronic bronchitis or em physem a................................................................G Pneum onia......................................................................................................... G Coughed up b lo o d ............................................................................................ G Problems with wheezing (whistling) in the c h e s t...................................... G None o f the a b o v e ............................................................................................ O S ) HEART AND BLOOD VESSELS E ar pain or discom fort................................................................................... O Have you e v e r had any o f the following? A feeling o f fullness.........................................................................................O Enlarged h e a rt................................................................................................... O E ar d ra in a g e ..................................................................................................... O H eart m irm u r.................................................................................................... O im b a la n c e .......................................................................................................... O A n g in a ................................................................................ Q D izziness (room spinning)............................................................................. O Myocardial infarction (heart a tta c k )..............................................................O S evere persistent ringing, buzzing o r roaring in the e a rs ..................... O Heart failu re ........................................................................................................O O ther e a r disease, symptom, o r inju ry....................................................... O Do you b y to protect your hearing by wearing earplugs or earm uffs when you are exposed to loud noise? Not exposed to loud n o is e .............................................................................O Alw ays (1 0 0 % )..................................................................................................O Usually (51 to 9 9 % )........................................................................................ O O ccasionally (21 to 5 0 % )..............................................................................O R arely (1 to 2 0 % )........................................................................................... O Never (0 % )........................................................................................................O ij M itral Valve P ro la p s e .......................................................................................O Abnormal EC G (electrocardiogram )............................................................O Ugh blood p ressure....................................................................... O Peripheral vascular disease (very poor circulation).............................. O Fingers becom e cold, white o r painful when hit or exposed to cold or vibration (e .g ., Raynaud's d is e a s e )..................................................O S tro k e ..................................................................................................................O H gh cholesterol level (2 0 0 or h ig h e r)......................................................... O Pain or cram ps in legs when w alkin g ...........................................................O Swelling in your legs or fee t (not caused by standing or w a lk in g ).... O Palpitations (rapid or irregular pounding o f the heart lasting seconds or m inutes) m ore than once p er m o n th .............................. O Difficulty sleeping without being propped-up (fo r example: using 3 or more p illo w s )......................................................................................O Phlebitis (Inflam m ation o f the veins) in the le g s ......................................O O ther heart disease, problem or d iso rd er.................................................. Q O ther cardiovascular sym ptom s................................................................... O 5567 Page 8 of 12 C Health Examinetics/Exemolar International (11/2003) AD Rights Reserved 000 000 0 000 as 7883 BLOOD la a Have you e v e r had any of the folowing? Hemophilia (bleeding p ro blem )................................................................. Sickle celt a n e m ia ......................................................................................... O ther a n e m ia ................................................................................................ Tendency to bruise easily or bleed excessively.................................. H ave recently noticed enlarged ' lymph'' glands or nodes ............... Abnormal hemoglobin or red blood c e lls ................................................ Been refused as a blood donor in the past 5 y e a rs ............................ o o o o o o o Received a blood transfusion (another person's blood) in the past 10 y e a rs ................................................................................................... O ther blood disease, symptom or injury................................................ o o U ) BONES, MUSCLES AND JOINTS Have you e v e r had a back strain or Injuy? In the past year..........................................................................O M ore than a year a g o ................................................................................... O Have you had any o f the following in the o ast y e a r? Back pains that prevented you from working (at hom e or a t a job) m ore than o n c e .......................................................................................... O B u rsitis....................................................................................... ...................... Q C arpal Tunnel Syndrom e............................................................................. O D egenerative disc d is e a s e ............................................................................ O Herniated disc or s c ia tic a .............................................................................. O Elbows or shoulders often sw olen and te n d e r...................................... O Finger joints often swollen and te n d e r..................................................... O G o u t..................................................................................................................... O Hips, knees or ankles often swollen and te n d e r.................................... O O steo arth ritis................................................................................................. O Pain in your hand(s) at night...................................................... O Rheum atoid arth ritis ..................................................................................... O Ten do nitis........................................................................................................... O W ake up in morning often with stiffness o r aching in joints or muscles............................................................................... O O ther bone o r joint disease, symptom, injury or surgery..................... O V ") GASTROINTESTINAL TRACT STOMACH, )NTe$TlNgS,.BOWELS Have you had any o f the following? Stom ach, peptic or duodenal u lc e rs .....................................................O Current non-repalred hernia (ru p tu re ).................................................. O Noticed blood in stools in the past year ............................................ O Recent definite change in bowel m ovem ent, appearance and/or frequ ency.............................................................................................. O Please fill in answer choices completely q p <2$ Right W rong W rong W rong GASTROINTESTINAL TRACT (continued) L IV E R Have you had any o f the following? C irrhosis................................................... Jaundice (yellow eyes or s k in ).......... Liver disease, trouble or dysfunction If you are over the age o f 40: Do you have your stool checked for hidden (occult) blood a t regu intervals (every 2 years)? Y e s ......................................................................................................... N o .......................................................................................................... I don't kn o w ............................................................. - .......................... Do you have regular (every 2 years) rectal exam inations (gloved finger) perform ed by a health professional? Y e s ................................................................ :....................................... N o ........................................................................................................... I d on i know Have you had a rectal exam ination using a sigmoidoscope or coionoscope In the past five y e a rs ? ............................................... W ) NUTRITION How many servings o f fruits and vegetables do you eat on a typical dav? (m ark one response only) Zero servings....................... O Four s e rv in g s .......................... One serving.......................... O Five servings ......................... Two servings .......................O Six servings ............................ Three servings .................... O Seven or m ore servings .... How many servings o f whole-grain cereals, whole-grain breads, brown rice, beans, or bran do vou e a t on a typical dav? (m ark one response only) Zero servings........................O One serving...........................O Two servings .......................O Three servirgs .................... O Four s e rv in g s ......................... Five s e rv in g s ......................... Six servings ........................... Seven o r m ore servings .... How many servings o f high-fat foods, such as those listed below , do you eat on a typical dav? (red m eat, processed m eats (bologna, hot dogs, sausage, etc.] fried foods, gravy, cream or butter sauces, mayonnaise, salad dressing, w hole-m ilk dairy products, etc.) (m ark one response only) Zero servings........................O O ne serving .......................... O Two servings .......................O Three servings .................... O Four servings ......................... Five s e rv in g s ......................... Six servin9 8 ............................ Seven or m ore servings .... 0000 0000 0000 5567 Page 9 of 12 Meafth xamineiics/Exempiar international (11/2003) All Righto Reserved A' * - EH 7803 em iF t Please fill in answer choices completely c jp < 5 Right W rong W rong W rong X ) NERVOUS SYSTEMS NERVOUS SYSTEMS (continued) 000000 000000 000000 H ave you had any of the following? Psychological or m ental d iso rd er................................................................ O S evere mood swings (e.g ., feeling up and down) within the past 6 m o n th s......................................................................................................... O Depression o r frequently feeling down, unable to enjoy life ..............O Frequent episodes o f nervousness or s tre s s ..........................................O Irritability and difficulty controlling te m p e r................................................ O Chronic Fatigue Syndrom e (C F S ) or Chronic Fatigue Im m une D eficiency Syndrom e (C F ID S ).............................................................. O Neuritis (pinched or inflam ed n erv e s)........................................................ O Difficulty falling asleep, staying asleep or awakening e a rly .................O Tend to have trouble concentrating (e.g . when calculating and doing arith m etic)........................................................................................O Tend to have trouble rem embering (e.g . difficulty with short term m em o ry)...................................................................................................... O H ead injury that caused you to black out (concussion) in the past y e a r............................................................................................................... O Fainted o r loss o f consciousness in the past y e a r................................O Feel dizzy, light-headed, excessive drowsiness (like you have been drugged)........... ................................................................................ O S evere headaches more than twice per year that w ere not relieved by non-prescription headache m edications...................... O A trem or (uncontrolled shaking) in the hands or le g s ...........................O N arco lep sy........................................................................................................ O Num bness or tingling in arm s (occurs every m o n th ).............................O Num bness or tingling In hands (occurs every m o n th )........................... O Num bness or tingling in feet (occurs every m o n th )................................O Loss o f feeling o r sensation in arm s, hands, legs o r feet (occurs every m o n th )........................................................................................ O Felt tired, worn out, sad or blue in the last 6 m o n th s........................... O Thoughts about suicide in the last 6 m onths............................................O O ther neurological or psychological disease, symptom, or in ju ry ...... O None o f the a b o v e ...........................................................................................O Frequent (at least once per w eek) problem with faintness o r lightheadedness that occurs when: Standing or getting out o f b e d ......................................................................O W alking or running...................................................................... O Climbing s ta irs ..................................................................................................O During the past month, w ere you under o r did you feel you w ere under strain, stress, or pressure? Yes, alm ost more than I could bear or sta n d ............................................ O Yes, som e; more than u su a l......................................................................... O Yes, some; about u su al..................................................................................O Yes, a little .........................................................................................................O Not at a ll.............................................................................................................O During the past month, did you feel sad, hopeless, discouraged, or did you have so many problems that you wondered if anything was worthwhile? Extrem ely so (to the point that I have just about given u p ). V ery m uch...................................................................................... Q uite a b it....................................................................................... Som e; enough to bother m e ..................................................... A little b it......................................................................................... N ot a t a ll......................................................................................... During the past month, how relaxed or tense w ere you? V ery re laxed .................................................................................. R elaxed ......................................................................................... . Som ewhat R e la x ed ........ ........................................................... A little te n s e .................................................................................. T e n s e .............................................................................................. V ery te n s e ..................................................................................... During the past month, how depressed o r cheerful w ere you? Very depressed................................................................................ D epressed......................................................................................... A little depressed............................................................................. Som ewhat c h eerfu l......................................................................... C h eerfu l............................................................................................. Very cheerfu l.................................. .................................................. ) OTHER ILLNESSES D o you have any other serious illness not m entioned throughout the questionnaire?................................................................................................ O A re you currently being treated by a health professional for a condition or d is e a s e ...................................................................................... O Do you have a m edical or personal problem you would like to discuss with a health professional?....................................................... Q HEIGHT AND WEIGHT Please provide your correct height and weight (WITHOUT SHOES by writing in the box and filling in the appropriate numbered bubbles. H E IG H T E Feet Inches X m im A K3 M o 0 rara P L E H EIG H T cFeet Inches 0 0 0 0 W E IG H T pounds m ooo ooo ooo ooo 5567 Page 10 o f 12 neaitn txanVneucs/txempiar International (11/2UU3) All Rights Reserved AA y FOR WOMEN ONLY Health Examlnetics understands that the following Inform ation is personal and confidential. T hese questions are necessary for assessing cancer risk. How long has it been since your last mam m ogram (breast X-ray)? In the past y e a r........................................................................................ 1 to 2 years a g o ....................................................................................... 3 o r m ore years ago................................................................................. N e v e r........................................................................................................... o o o o How long has it been since you had your breasts exam ined by a physician or nurse? In the past y e a r................................................................................................O 1 to 2 years a g o ...............................................................................................O 3 o r m ote years ago....................................................................................... O N e v e r.................................................................................................................. O H ave you received instruction on how to properly exam ine your breasts? Yes, and I perform once per m o n th ...................... O Yes, and I perform less than once per m onth..........................................O Yes, and I perform m ore than once per m o n th ........................................ O No or not s u re ...................................................................................................O How m any biopsies or needle aspirations o f the breast have you had? None o r Do not kno w ......................................................................................O O n e ..................................................................................................................... O Two or m o re ......................................................................................................O How long has it been since you had your last pap sm ear? In the past y e a r........................................................................ I to 2 years a g o ....................................................................... 3 o r m ore years ago................................................................. N e v e r........................................................................................... How old w ere you when your m enstrual periods started? I I or you ng er............................................................................ 1 2 t o 1 3 ...................................................................................... 14 or o ld e r.................................................................................. o o o o O o o How old w ere you when you had your first child? H ave not had a c h ild ...................................................................................... O 19 or you ng er................................................................................................... O 2 0 to 2 4 ..............................................................................................................O 25 to 2 9 .............................................................................................................. O 3 0 or o ld e r......................................................................................................... O Please fill in answer choices completely g p <5 Right W rong W rong W rong 5567 Page 11 o f 12 4 Health xamineticsyExemplar international (1 1/003) AN Rights Reserved as 7883 5567 Page 12 o f 12 Health Examhetics/Exempiar international (11/2603) All Rights Reserved TITLE PAGE Jack W. Leach, et al. v. E. I. du Pont de Nemours and Company Circuit Court of Wood County. WV. Civ Action No. 0I-C-608 Implementation Plan: May 1, 2003 Injunction Order Appendix No. 2 Study-Specific Standard Operating Procedure : Documentation. Accountability, and Sample Chain of Custody Requirements for the Shipping of Serum Samples IMPLEMENTATION DIRECTOR Robert L. Grob, Ph.D. Professor Emeritus, Analytical Chemistry 12 Birch Road Malvern, PA 19355-1644 (610) 651-0132 ANALYTICAL FACILITY MANAGEMENT John Flaherty Vice President of Operations Exygen Research 3058 Research Drive State College, PA 16801 (814) 272-1039 Page 1 of 8 DRAFT COPY Jack W. Leach, et al. v. E. I. du Pont de Nemours and Company Circuit Court ofWood Comity. WV.Civil Action No. Q1-C-6Q8 Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 ^ 1. SCOPE AND APPLICABILITY This SOP governs the documentation, accountability, and sample chain of custody requirements for the shipment of serum samples to the analytical facility. 2. REPONSIBILITIES 2.1 The Good Laboratory Practices (GLP) Expert and Analytical Facility Management are responsible for conducting the necessary training covering proper documentation, accountability, and sample chain of custody requirements. This training will, at minimum, be given to the Principal Contact from each of the three clinics. 2.2 The phlebotomist who performs the blood collection is responsible for ensuring that the Chain of Custody/Analysis Request Form (COC) (Figure 1) is completely and correctly filled out and signed by staff members who package and ship the serum samples. 2.3 The Principal Investigator at the analytical facility is responsible for ensuring that the chain of custody remains intact after the samples are received by the analytical facility. 3. DEFINITIONS GLP Expert: Patricia D. Royal, M.S., President, Quality Systems Consultants, Inc., 80 Main Street, Plympton, MA 02367 (781)585-9370 Analytical Facility Management: John Flaherty, Vice President of Operations, Exygen Research 3058 Research Drive, State College, PA 16801 (814) 272-1039 Principal Investigator: Emily Decker, Scientist Exygen Research, 3058 Research Drive, State College, PA 16801 (814)272-1039 Page 2 of 8 Jack W. Leach, et al. v. E. I. du Pont de Nemours and Company Circuit Court ofWoodCounty.WV. Civil ActionNo,Q1-C-6Q8 Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 4. MATERIALS AND EQUIPMENT 4.1 Chain of Custody/Analysis Request Forms, triplicate design. 4.2. A readily available source of dry ice pellets. Also, necessary personal protective equipment appropriate for handling dry ice. 4.3 Coolers numbered and coded with the clinic s unique identification assigned for this project. They must be purchased from Uline Shipping Supplies Specialists. The Uline part number for the required coolers is S-7888. (This part number corresponds to a package which includes one 19 x 12 x 12.5 cooler and one shipping box). These will be provided to each clinic. 4.4 Plastic bags for use as secondary sample packaging prior to shipping. These will also be obtained from Uline, part number S-1707 (3 x 5 , 4 mil reclosable poly bags, 1000 per carton). These will be provided to each clinic. 5. PROCEDURE 5.1. Before collecting any blood, the completed and signed consent form must be verified. When each sample is collected the clinic will assign a unique alphanumeric identification code to each sample based on the clinic s identification code and patient code. This number will be entered into the Clinic Sample Identification column of the COC sheet. Likewise, the date and time of each blood sample collection will be recorded, and the date and time that the serum sample preparation is completed will be entered into the appropriate column on the COC sheet. 5.2. Coolers will be provided to each clinic (see section 4.3 above). Each cooler will be assigned a unique alphanumeric identification number, which will be written on the cooler. Each clinic will derive its own cooler numbering system, the only condition being that each number contains the clinic s identification code. 5.3. Before packaging, the primary serum sample containers must be placed individually into small plastic bags as secondary packaging (which will also be provided to each clinic; see section 4.4 above). The secondary packaging must have the unique Clinic Sample Identification sample code written o n it in permanent black ink. 5.4. Before the samples are packed in dry ice, a person other than the packager will verify that the samples documented on the COC form match exactly with those being packed in the cooler. The verifier then initials and dates the Cooler Contents Verified prompt. Page 3 o f 8 Jack W. Leach, et al. v. E. 1. du Pont de Nemours and Company Circuit C ourt of Wood County. WV, C M Action No, O l i -608 Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 5.5.Samples are to be dispersed in a cooler full of dry ice pellets, arranged in such a way as to minimize the possibility of impact, and such that they are completely covered with the pellets. The cooler must be completely filled with dry ice pellets. No more than 20 samples are to be placed in one cooler. The cooler will be covered promptly after packing with dry ice pellets to minimize loss of dry ice to sublimation. 5.6. The time between the completion of serum preparation and packaging for shipment must be able to be accounted for on the COC page. There must not be any unexplained gap in the chain of custody for the samples. 5.7. After the serum samples are packaged, the Cooler ID# prompt will be completed. Section 2 ( P ersonnel Involved in Shipment of Samples ) of the COC form also will be completed at this time, if it has not been previously. The printed name, signature, initials and date of signature need to be recorded for each person who entered information anywhere on the form. The page number prompts also need to be filled in. 5.8. The person who packaged the samples then completes the first line in the Relinquished by section, and verifies that any unused prompts are lined out. 5.9. The COC form is then faxed to Exygen Research Sample Receiving using the fax number at the top of the form. After it is faxed, the pink copy is removed and becomes part of the clinics records. The white original and yellow copies are to be placed in an envelope, which is then placed into the shipping carton with the cooler that contains the samples to which the COC form corresponds. 5.10. The serum samples are required to be shipped to Exygen Research Sample Receiving at the address given at the top of the COC form by FedEx overnight delivery. This is the only carrier and method of shipment that is acceptable. 5.11. Upon receipt of the samples by Exygen Research, the chain of custody procedure will follow Exygen SOP V401, Contract Research Sample Handling . After Exygen Sample Receiving complete s the Received by section, a copy of the COC will be faxed back to the clinic, which will be kept with the clinic s records for this study. 5.12. Any problems with delivery or condition of samples upon arrival at Exygen will be documented. The Exygen Principal Investigator will notify the clinic and the Implementation Director of any problems immediately. Page 4 of 8 Jack W. Leach, et al. v. E. 1. du Pont de Nemours and Company Circuit Court ofWood County.WV, CM Action No, 01-C-6Q8 Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 5.13. Correction and Clarification of Raw Data 5.13.1. As soon as any information has been entered on the COC form, it becomes raw data. At this point, this form is not to be discarded for any reason. If it becomes damaged, information may be transcribed onto another sheet, but the transcription process will be documented via footnote on the new page. The original damaged sheet must be attached to the transcribed page. 5.13.2. If errors are made in handwritten entries, or if clarifications are to be made, the errant information will be crossed out with a single line, so as not to obscure the original entry. Then, depending upon the nature of the error, an appropriate error code is chosen (see Figure 2), and the error code is initialed and dated. If the error is more complex than what is covered by the error code list, a detailed explanation will be provided by footnote on the COC page. 5.14. See Figure 3 for a properly filled out COC form, and for examples of the use of the error coding system. 6. REFERENCES Exygen Research SOP V401, Contract Research Sample Handling 7. FIGURES Figure 1. Chain of Custody/Analysis Request Form Figure 2. List of Error Codes Figure 3. Example COC Sheet and Use of Error Codes 8. SIGNATURES (SOP becomes effective on the date it is signed by the implementation director) Robert L. Grob, Ph.D. Implementation Director Date John M. Flaherty. Analytical Facility Management Page 5 o f 8 Date Jack W. Leach, et al. v. E. /. du Pont de Nemours and Company Circuit Court o f Wood County. WV. Civil Action No. 01-C-608 Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 Figure 1. Chain of Custodv/Analvsis Request Form CHAIN OF CUSTODY tTtiAiCH 14 .1580to * 9m*pimt m itiNN MX: .S l 14Mfc . Itami %0mM a..PM!MUM) iirwIB'" p ern ii iiw i) 4 th#vwiAarilan mustbe ntlMtadta I nvt to reamfiriyti*pbatMMntftmtht rum prepanttan nf a fttotnot* tu if bottom ofw# pap. UcfcnMnwfomoiriinformi M l T I M Fm RFVmRi fM tu,lAitiiiaanddate aboM. Lineout unumprompt Tassar MaSvMta Ifmorompi^ tfd M U tM MB M t Page 6 of 8 Jack W. Leach, et al. v. E. I. du Pont de Nemours and Company Circuit C ourt o f Wood County. WV. Cjyfl ActtoilNq. 0L-C-6(& Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 Figure 2. List of Error Codes EXPLANATION OF ERROR CODING Correction of raw data is made bv drawing a single line through the erroneous data and/or write-over, and filling in the correct data. Care must be taken not to obscure the original entry. The correction is initialed and dated bv the individual making the correction, and an explanation is given for the correction. The following error codes shall be used to explain corrections: (wl) Inadvertently recorded in Wrong Location (cc) Changed for greater Clarity (wo) Write Over (Technician inadvertently wrote over the error instead of drawing a line through the error) (sp) Spelling error (ir) Inadvertently not Recorded at time of initial observation (ce) Calculation Error (re) Recording Error (ne) Numerical transcription Error (ee) Entry not initialed and dated at time of entry (te) Transcription Error (wd) Wrong Date entry (sm) Stray Marks appearing on data with no other feasible explanation (le) Late Entry (tl) Technical error Codes, other than those defined above may be used, if explained or defined by footnote on the COC form. Errors that cannot be explained using an error code must be fully detailed at the time of correction. Error codes are to be circled and written above or close to the correction. If this is not feasible, the error should be footnoted with an asterisk or other symbol, and explained at the bottom of the page. Page 7 of 8 Jack W. Leach, et al. v. E I. du Pont de Nemours and Company Circuit CourtofWood County. WSLClvfl ActionNo. 01-C-60S Implementation Plan: May 1,2003 Injunction Order Appendix No. 2 Figure 3. Example COC Sheet and Use of Error Codes f RESEARCH CHAIN O F CUSTODY Exyfsn RwMMth Sample Itorsiving IM S totearcli Ortv* Stato Collagt, PA 16801 Tr814 331.8032 www.wygenrewarth.com FAX: 814.231.1580 C ilN IC IN F O R M A T IO N Clinic (nam e & address): Nlame nf Clinic. A o tircS i C ity ,.S in k t , fieri*) if <W t STAFF I M V O L V m IF, S A M P l F S H IP M F N T 1 . R ,C . M u r a e _______________ {Prieteii Nanti % /?. / u a j j l SiCMtuw 2 . J T lM - P . t M - f P . 8 c d a ih fo mwiwoaw Clinic 1dentilication Code; A Phone: fa re s i W e ) 7 -d ittif * _____________ Fa: f o r t * , to d e ) ' l - r t t j f r * Email: E tM ii I f i c i i n f t COm SigAtuie ^ 2 X S W .tk (Phrtitd Mam#} Sipfm ' lnialviB -rS O f-i-O mUNM* mustbe verified packaged by adding a footnote to the bottom of the p a l* Each person who enters inform ation on this form must add their nam e, signature, initials, and date above, lin e out unused prompts ..........Tifli..................... OllirltA l|jrl A/A mlu lti U-*" Aim*!<ii> <nMa a ih tlo i IITJEAW iltfliMt r i x tin tizcpm enhila J'obfn o ih t la &a> pp\ oil it 1*1__ m m til lit} a m s' .......... ^s^ ~ s^ : ^ ,/ PLEASE FAX THE COMPLETED FORM lu bygenSans* Kecwr Cooler Contents Wfe3~ priortoshppng samples. ________ initia)&Pstt* ^5 tfF-UM3 AKEEPTHEP h i* COPYanriodidetf*alliw ivvnvw *h sampleViipment Cooler IQ # : / JCA/ tf/jtfa m L a-te 2. V. 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