Annex A: Data Fields in the Data Collection Form

A1.0 Data Fields applicable to HMCS Chicoutimi Subjects Only

  • Subject location at the onset of the fire;
  • Respiratory protection used during the fire (type used, time to don, use details);
  • Firefighting activities;
  • Symptoms experienced from time of fire until arrival in Faslane on 10 October 2004;
  • Medical assessment or treatment received from time of fire until arrival in Faslane;
  • Symptoms reported by subject at initial medical assessment in Faslane;
  • Clinical findings noted by clinician at initial medical assessment in Faslane;
  • Spirometry results from Faslane (FVC, FEV1, FEV1/FVC, PEF);
  • Laboratory results from Faslane (hemoglobin, hematocrit, MCV, platelets, WBC, neutrophils, lymphocytes, ALT, AST, GGT, Alk Phos, BUN, creatinine); and
  • Additional comments related to subject’s medical condition from time of fire to completion of Faslane medical assessment that was not already captured.

A2.0 Data Fields applicable to All Subjects

a. Date of Birth and CAF Service History

  • Subject study identification number;
  • Subject Status (Chicoutimi, Control, Care & Custody);
  • For Care & Custody team only: start and end date in Faslane;
  • Date of Birth;
  • CAF Enrolment Date;
  • Posting history (Unit/location, start date, end date);
  • Service Status (Currently serving or released as of 31 December 2009);
  • If released:
    • Release date;
    • Release type (e.g., 3B, 4A, etc.);
    • Medical conditions present at release (as documented in release medical);
    • Release medical conditions believed to be attributable to CAF service; and
    • Release medical conditions believed to be attributable to HMCS Chicoutimi fire.
  • Rank as of 5 October 2004; and
  • MOC / MOSID as of 5 October 2004.

b. Health Status as of 5 October 2004 (most recent information available prior to 5 October 2004)

  • Height and date recorded;
  • Weight and date recorded;
  • Blood pressure and date recorded;
  • Smoking status and source information date;
  • Alcohol intake and source information date;
  • Exercise (yes/no, hours per day/week, express test results) and source information date;
  • Audiogram (date and results for the most recent audiogram just prior to 5 October 2004 plus earliest audiogram in CAF medical record);
  • Family history (text field);
  • Medications prescribed between 5 October 2003 and 4 October 2004 (medication name, dosage, ATC Level 1, start date, amount prescribed if single prescription);
  • Chest x-ray (date, report comments);
  • Pulmonary function test (date, report comments, FVC, FEV1, FEV1/FVC, FEF25-75%, FEF50%, FEF75%, PEF, post-bronchodilator FVC and FEV1, TLC, DLCO, DLCO/VA);
  • Methacholine challenge test (date, report comments, PC20);
  • Electrocardiogram (date, report comments);
  • Additional investigations (for each: date, investigation type, indication and report comments);
  • Complete blood count (date, hemoglobin, hematocrit, MCV, platelets, WBC, neutrophils, lymphocytes);
  • Liver function tests (date, ALT, AST, GGT, alk phos);
  • Fasting blood glucose (date, value);
  • Renal function (date, BUN, creatinine);
  • Lipid profile (date, total cholesterol, HDL, LDL, triglycerides);
  • Urinalysis (date, result comments if abnormal); and
  • Additional laboratory tests (for each:  date, test name, test results, indication and additional comments).

c. Past Medical History (complete data from enrolment date until 5 October 2004)

  • Sick leave (reason, diagnostic category, start date, number of days);
  • Temporary medical employment limitations (limitation description, reason for MEL, start date, number of days);
  • Temporary medical “G” or “O” categories with a value of three or greater (G category, O category, reason for TCat, start date, number of days);
  • Permanent medical employment limitations (limitation description, reason for MEL, start date);
  • Permanent medical “G” or “O” categories with a value of three or greater (G category, O category, reason for TCat, start date);
  • Past medical history of respiratory conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Past medical history of ear, nose, and throat conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Past medical history of cardiovascular conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Past medical history of gastrointestinal conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Past medical history of mental health conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details)
  • Past medical history of neurological conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Past medical history of other significant conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details for conditions not previously described in other preceding past medical history textual narratives that either frequently occurred, were chronic in nature, or were significant events such as surgery or hospitalization); and
  • Past history of unusual hazardous exposures (textual narrative to include date, description of event and exposure, clinical effects).

d. Post-Fire Information (most recent information available just prior to 31 December 2009 or date of release)

  • Rank;
  • MOC / MOSID;
  • Height and date recorded;
  • Weight and date recorded;
  • Blood pressure and date recorded;
  • Smoking status and source information date;
  • Alcohol intake and source information date;
  • Exercise (yes/no, hours per day/week, express test results) and source information date; and
  • Audiogram (date and results).

e. Post-Fire Medical History (complete data from 5 October 2004 to 31 December 2009 or date of release)

  • Medications prescribed (medication name, dosage, ATC Level 1, start date, end date);
  • Sick leave (reason, diagnostic category, start date, number of days);
  • Temporary medical employment limitations (limitation description, reason for MEL, start date, number of days);
  • Temporary medical “G” or “O” categories with a value of three or greater (G category, O category, reason for TCat, start date, number of days);
  • Permanent medical employment limitations (limitation description, reason for MEL, start date);
  • Permanent medical “G” or “O” categories with a value of three or greater (G category, O category, reason for TCat, start date);
  • Medical history of respiratory conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of ear, nose, and throat conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of cardiovascular conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of gastrointestinal conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of mental health conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of neurological conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details);
  • Medical history of other significant conditions (textual narrative to include date, diagnosis, treatment, and any additional pertinent details for conditions not previously described in other preceding post-fire medical history textual narratives that either frequently occurred, were chronic in nature, or were significant events such as surgery or hospitalization);
  • History of unusual hazardous exposures (textual narrative to include date, description of event and exposure, clinical effects);
  • Chest x-rays (for each: date, report comments);
  • Pulmonary function tests (for each: date, report comments, FVC, FEV1, FEV1/FVC, FEF25-75%, FEF50%, FEF75%, PEF, post-bronchodilator FVC and FEV1, TLC, DLCO, DLCO/VA);
  • Methacholine challenge tests (for each: date, report comments, PC20);
  • Electrocardiograms (for each:  date, report comments);
  • Additional investigations (for each:  date, investigation type, indication and report comments);
  • Complete blood count (for each:  date, hemoglobin, hematocrit, MCV, platelets, WBC, neutrophils, lymphocytes);
  • Liver function tests (for each:  date, ALT, AST, GGT, alk phos);
  • Fasting blood glucose (for each:  date, value);
  • Renal function (for each:  date, BUN, creatinine);
  • Lipid profile (for each:  date, total cholesterol, HDL, LDL, triglycerides);
  • Urinalysis (for each:  date, result comments if abnormal); and
  • Additional laboratory tests (for each:  date, test name, test results, indication and additional comments).

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