visit information
visit number BLS$CDS$FIX, BLS$CDS$RX,
BLS$CDS$DX, usually as part of
the key rather than a data
item
date of visit BLS$CDS$FIX
current status BLS$CDS$NL
demographics
date of birth BLS$CDS$NL
education BLS$CDS$FIX
marital status BLS$CDS$FIX
race BLS$CDS$NL
employment and occupation BLS$CDS$FIX
personal and family income BLS$CDS$FIX
anthropometry
height BLS$CDS$FIX
weight BLS$CDS$FIX
handedness BLS$CDS$FIX
physical examination and medical history
men's and women's medical
history and physical (H&P) BLS$CDS$FIX
blood pressure BLS$CDS$FIX & H&P
pulse rate H&P
fasting blood sugar BLS$CDS$FIX
CHD class BLS$CDS$FIX
hearing and eye test results BLS$CDS$FIX
visual acuity BLS$CDS$FIX
diagnosis list BLS$CDS$DX
standard laboratory values BLS$CDS$FIX
health promotion and health risk behaviors
smoking BLS$CDS$FIX
exercise activity calories BLS$CDS$FIX
diet data BLS$CDS$FIX
self-rated health status
Cornell Medical Index BLS$CDS$FIXself-rated health status H&P
Blessed mental status BLS$CDS$FIX
CES-D BLS$CDS$FIX
medications
prescription medications BLS$CDS$RX
morbidity
hospitalizations and major
illnesses BLS$CDS$HI
medical procedures performed BLS$CDS$PRC
mortality
date of death BLS$CDS$NL
cause of death BLS$CDS$NL
autopsy status BLS$CDS$NL
data type source(s) activities and attitudes questionnaire 501-1 activity calories 142-1 audiometry (thru 8/31/90) 601-1, 601-2 audiometry (since 9/1/90) 603-1 autopsy study status BLS$CDS$NL basal metabolism 141-2 body composition 161-2 calories 142-1 CES-D 290-12 cgtt 122-2 clamp 128-2 color vision 611-1, 611-2 Cornell Medical Index 4-1 current status BLS$CDS$NL death info, date and cause BLS$CDS$NL demographic questionnaire 804-1, 804-2 diagnoses BLS$CDS$DX drugs BLS$CDS$RX EKG-CAD classification 7-1 ethnicity BLS$CDS$NL examination, men 1-5 thru 1-9 examination, women 901-8 thru 901-13 fasting blood sugar 120-2 thru 131-2 follow-up study status BLS$CDS$NL fpg 125-2 handedness 161-11, 290-1 history, first since 1991 810-1 thru 801-15 history, interval since 1991 805-1 thru 805-12 history, men (1958-1991) 1-1 thru 1-4 history, women (1978-1991) 901-1 thru 901-7 history, personal smoking 409-1 hospitalizations BLS$CDS$HI illnesses BLS$CDS$HI interval history, since 1991 805-1 thru 805-12 iv-ex 127-2 iv-post-ex 129-2 ivgtt 120-2 ivitt 124-2 laboratory results 2-1 thru 2-4medical diagnoses BLS$CDS$DX medical history, first since 1991 810-1 thru 801-15 medical history, interval since 1991 805-1 thru 805-12 medical history, men (1958-1991) 1-1 thru 1-4 medical history, women (1978-1991) 901-1 thru 901-7 medical laboratory 2-1 thru 2-4 medications BLS$CDS$RX mental status 290-9 neurological exam 290-1, 290-9, 290-12 nutrient intake 301-18, 308-18 ogtt 121-2 ogtt, 3 hour 131-2 oral glucose test 130-2 physical examination, men 1-5 thru 1-9 physical examination, women 901-8 thru 901-13 prescriptions BLS$CDS$RX procedures, surgical & test BLS$CDS$PRC race BLS$CDS$NL smoking history 409-1 status BLS$CDS$NL surgical procedures BLS$CDS$PRC test procedures BLS$CDS$PRC tonography 611-1, 611-2 trt 123-2 vision 611-1, 611-2 visit date 0-1
Please print or type all information.
1. Name:
2. Date:
3. Briefly describe the nature of your research:
4. VMS Username:
5. Are you an employee of GRC? Yes No
If the answer to 5 is Yes, please answer 6 & 7, and sign the certification at the bottom.
6. GRC room number:
7. Telephone extension: E-mail address:
If the answer to 5 is No, you must be collaborating with a BLSA researcher who will serve as
your sponsor.
Please complete 8 and 9, and have your BLSA sponsor answer 10 through 13, and both you and
your sponsor
must sign the certification at the bottom.
8. Applicant's address:
9. Applicant's telephone number:
10. Sponsor's Name:
11. Sponsor's GRC room number:
12. Sponsor's Telephone extension: E-mail address:
13. During what time period will the applicant be using these data?
From: Until:
Privacy Act Notification and Certification:
I understand that the BLSA files are a system of records within the scope of PL 93-579, the
Privacy Act of
1974, This dictates that the information contained in the files may be disclosed only on a
"need-to-know"
basis. I understand that it is my responsibility to ensure that there is no unauthorized disclosure
of these data.
I agree that the data will be used only for the purposes stated above, and that none of these data
will be
released in whole or in part to any person or organization who has not been authorized to receive
them. I agree
that, should the identity of any person described in the system be disclosed inadvertently, the
Data
Management Services staff of the Research Resources Branch will be immediately advised of the
incident. Upon
completion of the intended analysis, I agree that the access-enabling information and format
documentation
will be returned or destroyed, and no copy of identified records will be retained. I agree that I
will be
responsible for any and all legal implications of unauthorized disclosure, if disclosure is due to
my actions,
either intentional or inadvertent.
Signature of Sponsor (required if #5 is No)
Signature of Applicant
As a courtesy to other researchers who use these data, and in return for the privilege of using
these data in my
research, I will supply the DM staff with information relating to errors and omissions in these
data, as well
as other data items that relate to the BLSA and should be part of the BLSA database.
Please print or type all information.
Name: Date: Telephone number: E-mail address: Type of Error: Data is incorrect Data is incomplete or missing Please describe the nature of the error: If you have any idea as to the source of the error, please indicate what it is: Corrections or additions may be provided on floppy disk or, if they are manageable, on hard copy below. Please remember to include identifying information (normally xray and visit, at a minimum) so that data may be properly filed. Correction is on the accompanying floppy disk: Filename: File format (data items and columns defined for fixed data, or delimiters used for variable data): Correction is as noted below:
Please print or type all information.
Name:
Date:
Telephone number: E-mail address:
This request must be approved by the BLSA Steering Committee before it can be honored by the
Data Management Services staff of the Research Resources Branch. Please complete this form
andsubmit
it to the Steering Committee, which will forward it to Data Management Services when and if it
is favorably acted upon.
Type of Action: Addition to dataset Deletion from dataset
Describe the data that should be added or deleted:
Why is this data of general interest to justify addition, or no longer of interest to justify deletion?
What is the source of this data item(s)?
BLSA masterfile, or
BLSA researcher:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Action by the BLSA Steering Committee:
Approved Disapproved
By: Date:
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