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3~' <br />29. IS YOUR «PERSON'S» CANCER ACTIVE OR IN REMISSION? <br />Iverson alive, select active or remission based on response. <br />30. WHAT IS THE NAME OF YOUR «PERSON'S» PRIMARY PHYSICIAN <br />Record first and last name of person's physician,. <br />31. WHAT IS THE NAME OF YOUR «PERSON'S» ONCOLOGIST? <br />Record first and lasC name of oncologist, <br />Special Instructions: If' you need to explain what an oncologist is, state that an oncologist is a <br />physician that treats cancer. <br />32. WHAT IS THE NAME OF THE MEDICAL PRACTICE, HOSPITAL OR FACILITY <br />THAT PROVIDED TREATMENT: <br />Record the name, address, city, state, and zip for each facility. <br />33. MEDICAL RELEASE INFORMATION <br />Select YES or'NO based on the response. <br />Special Instructions: If asked why this information is needed, explain that it's possible that a <br />further look into your «person's» cancer history may be needed for this study. Ask person <br />if they would be willing to allow the Orange County Health Department to review their <br />medical files and if they would be willing to provide copies of their medical files. Explain that <br />only medical files concerning cancer reported during this interview would be needed.. If <br />person says yes, explain that a medical release statement will be required and that all medical <br />information obtained will remain confidential and stored in accordance with confidentiality <br />laws.. <br />34. MAY I CONFIRM YOUR HOME PHONE NiJMBER INCASE I NEED TO CALL <br />BACK? <br />Record telephone number with area code. <br />Data Entry Format: ###-###-#### <br />35. IS THERE AN ANOTHER PHONE iVLJMBER THAT YOU COULD BE REACHED <br />AT? <br />Record telephone number with area code, <br />Data Entry Format: ###-###-#### <br />3G. WHAT'S THE BEST TIME TO CONTACT YOU? <br />Record preferred time of day. <br />Work History (related to cancer victim) <br />37. WHAT IS YOUR «PERSON'S» CURRENT OR JOB OR OCCUPATION? <br />Record the stated,job or occupation, <br />Special Instructions: If interviewee says they're unemployed or retired, skip to Question 41. <br />Use past tense if person is deceased. If cun~ently employed, go to next question. <br />Page 32 of 47 <br />