This color indicates a required field. saminame ssn last5 sigi sex sbdob siceiden sicerfdt sicerfpc sicerfwh sicerfge sicerfpu sicerfon sicerfsc sicerfot sicerfoo sicechrt sicemhlc sicemhhs sicemhot sicemhoo sicecepc sicecenc siceceho sicecepr siceceot siceceoo siceshqd siceshpy siceshnc siceshot siceshoo sipedisc sipedc sipecnip sipecnte sipecnth sipecnml sipecnpp sipecnvd sipecnot sipecnoo siperslt sipecmnt sidc silnip silnph silnth silnml silnpp silnvd silnot silnoo sipav sipsa sipan sipcn sipc sips sipz sipcr sippn sirs siesm siesq sies sicpd sisny siq sicep sicadx sicadxl siptct siptctl siidmdc sildct siclin sipcrn sistatus sicectap sistachg sidod sistreas PATIENT SSN """last5""" Self-identified gender Birth The participant was identified as a potential lung screening candidate by: Date of referral Specialty of referring provider Eligible based on chart review? Medical History Receiving Care Elsewhere Smoking History Was a pre-enrollment discussion held? Pre-enrollment discussion date The lung screening program reached the participant or was contacted via (check all that apply): A pre-enrollment discussion with the participant resulted in: Intake discussion date The lung screening program reached the participant or was contacted via (check all that apply): Primary address verified? Preferred address Phone number Rural status Smoking History Smoking cessation education provided "Lung CA Dx (if applicable)" Any prior CT Informed decision making "Based on this information, the veteran has opted to" Clinical Indications for Initial Screening CT Participant communication record Current Status Reason for change Date of death Explanation Calculated Assigned sex Date "(If Lung Screening program outreach or self-referred selected, skip to column Q)" Primary Care Women's Health Geriatrics Pulmonology Oncology Smoking Cessation Other Specify "(If yes, skip to column AG)" Lung cancer Health status Other Specify Followed in pulmonary clinic Followed in nodule clinic Followed in hematology-oncology Private care Other Specify Quit date greater than 15 years Less than 20 pack years "Non-cigarette use (e.g. pipe, smokeless, vape, cannabis)" Other Specify "(If no, skip to column AS)" In person Telephone TeleHealth Mailed letter Message in Patient Portal VA Video Connect Other Other contact method (specify) In person Telephone TeleHealth Mailed letter Message in Patient Portal VA Video Connect Other Other contact method (Specify) Street Address Apt # County City State ZIP/Postal code Country "Ever smoked? (If ""Never"", skip to BS)" Willing to quit? Comments Cigarettes smoked per day? Number of years? "Quit date (if any)" Specify Date Location if not in VA Date Location if not in VA Enrollment CT Appointment "LAST,FIRST MIDDLE SUFFIX" 000-00-0000 Select Select yyyy-mm-dd Select yyyy-mm-dd Select Select Select Select Select Select Select Describe Select Select Select Select Describe Select Select Select Select Select Describe Select Select Select Select Describe Select yyyy-mm-dd Select Select Select Select Select Select Select Describe Select Comment yyyy-mm-dd Select Select Select Select Select Select Select Describe Select Insert Insert Insert Insert Insert Insert Insert +1 (000) 000-0000 Select Select Select Comment Number Number yyyy-mm-dd Describe yyyy-mm-dd Describe yyyy-mm-dd Describe Select Select Describe Describe Select yyyy-mm-dd Select yyyy-mm-dd Describe "Mouse,Mickey" 999-99-0010 M0010 Male Male 1945-08-14 "Referral (e.g., E-consult)" 2021-11-23 Yes LC Research Yes Yes 2021-09-23 Yes Participant is unsure of lung screening. Ok to contact in the future. 2022-01-03 Yes Yes 338 Flower Lane King Petunia WA 98444 555-674-9999 Urban Never Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team Active 2022-01-14 "Mouse,Minnie" 999-99-0011 M0011 Female Female 1947-11-24 Low-dose CT placed directly by clinician 2021-11-14 Yes Yes Yes 2021-10-18 Yes Participant is interested in discussing lung screening. The program will proceed with enrollment process. 2022-01-04 Yes Yes 338 Flower Lane King Petunia WA 98444 555-674-9998 Urban Current "Smokes like a chimney, never plans to stop" 40 35 None Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team Active 2022-01-14 "Duck,Daffy" 999-99-0012 D0012 Male Male 1945-12-16 Lung screening program outreach No Yes "Duck,Huie" 999-99-0013 D0013 Non-binary Male 1957-06-23 Self-referred Yes No 2022-01-03 Yes Telepathy Yes 542 Petal Road 1 King Petunia WA 98444 555-674-8921 Rural Past 20 18 2018-01-01 None 2015-05-06 Virginia Mason Not applicable "Duck,Louis" 999-99-0014 D0014 Male Male 1958-05-16 Self-referred Yes 2022-01-04 Yes Yes 542 Petal Road 2 King Petunia WA 98444 555-674-7854 Rural Current Yes The Usual Not applicable "Duck,Dewey" 999-99-0015 D0015 Transmale/Transman/Female-to-Male Male 1959-04-24 Self-referred No Yes Being treated currently Not enroll "Duck,Daisy" 999-99-0016 D0016 Female Female 1947-10-25 Low-dose CT placed directly by clinician 2021-11-15 Yes Yes Yes 2021-11-15 Yes Participant is not interested in discussing lung screening in the future. 2022-01-12 Yes Yes 3062 Quackers St. Pierce Duck Lake WA 98155 555-984-5623 Urban Current Yes 40 20 Quit line Not enroll at this time -- okay to contact in the future Active 2022-01-20 "Dog,Goofy" 999-99-0017 D0017 Male Male 1952-11-14 Lung screening program outreach Yes 2022-01-13 Yes Yes 3062 Quackers St. Pierce Duck Lake WA 98155 555-984-5624 Urban Current Yes 20 20 Quit line Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team Meets criteria Active 2022-01-20 "Dog,Pluto" 999-99-0018 D0018 Male Male 1952-11-15 Low-dose CT placed directly by clinician 2021-11-30 Yes Yes 2022-01-12 Yes Yes 3062 Quackers St. Pierce Duck Lake WA 98155 555-984-5625 Urban Current Yes 18 20 Quit line Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team Meets criteria Active 2022-01-20 Burden of cost "Cricket,Jiminy" 999-99-0019 C0019 Male Male 1952-11-16 "Referral (e.g., E-consult)" 2021-11-29 Yes Yes 2022-01-15 Yes Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team Meets criteria "Fairy,Blue" 999-99-0020 F0020 Female Female 1952-11-17 Self-referred No Yes Ethereal Yes 2021-12-04 Yes Participant is interested in discussing lung screening. The program will proceed with enrollment process. "McDuck,Scrooge" 999-99-0021 M0021 Male Male 1940-02-23 "Referral (e.g., E-consult)" 2021-12-14 Yes Yes Yes 2021-12-20 Yes Participant is interested in discussing lung screening. The program will proceed with enrollment process. Not active Deceased 2022-01-01 Heart attack "White,Snow" 999-99-0022 W0022 Female Female 1952-05-16 Low-dose CT placed directly by clinician 2021-12-13 Yes No Yes Poison confuses results 2022-01-03 Yes Yes 1 Miners Road King Coal WA 98654 555-876-9874 Rural Never lSecond hand smoke exposure Not applicable Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team 30 years of sustained second hand smoke Active 2022-01-30 "Dwarf,Doc" 999-99-0023 D0023 Male Male 1943-09-08 Lung screening program outreach Yes 2022-01-03 Yes Yes 1 Miners Road King Coal WA 98654 555-876-9874 Rural Current 16 85 Referral to PCP Discussion complete Not enroll at this time -- okay to contact in the future Not active "Dwarf,Happy" 999-99-0024 D0024 Male Male 1944-09-08 Self-referred Yes 2022-01-04 Yes "Dwarf,Grumpy" 999-99-0025 D0025 Male Male 1945-09-08 Self-referred Yes 2022-01-04 Yes Yes 1 Miners Road King Coal WA 98654 555-876-9874 Rural Current Yes 25 75 Gave number for stop smoking line Discussion complete Enroll in the Lung Screening program and have an LDCT ordered. Coordination of care will be made by the LSS team "Unexplained cough, pack-years meet criteria" Active 2022-01-22 "Dwarf,Sleepy" 999-99-0026 D0026 Male Male 1946-09-08 Self-referred Yes 2022-01-05 Yes Yes 1 Miners Road King Coal WA 98654 555-876-9874 Rural Past 2021-01-01 2020-02-06 Fred Hutchinson 2020-06-06 Fred Hutchinson Discussion complete Not enroll at this time -- okay to contact in the future Not active "Dwarf,Sneezy" 999-99-0027 D0027 Male Male 1947-09-08 Self-referred No Yes "Dwarf,Bashful" 999-99-0028 D0028 Male Male 1948-09-08 Self-referred No Yes Yes "Dwarf,Dopey" 999-99-0029 D0029 Male Male 1949-09-08 Self-referred No Yes