1. Annual Status Report

NWTSID - ok to leave blank if unknown

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* NWTSID - ok to leave blank if unknown

Email Address

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* Email Address

Participant's Initials

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* Participant's Initials

Participant's Date of Birth

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* Participant's Date of Birth

Zipcode

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* Zipcode

How would you prefer to be contacted in the future regarding Annual Status Reports?

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* How would you prefer to be contacted in the future regarding Annual Status Reports?

Serious illness or other conditions resulting in hospitalization/surgery or medical treatment since last report?

If yes please use the spaces below to report each event
Events to report

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* Events to report

First Event

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* First Event

First Event Date

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* First Event Date

Description/Outcome/Treatment of First Event

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* Description/Outcome/Treatment of First Event

Second Event

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* Second Event

Second Event Date

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* Second Event Date

Description/Outcome/Treatment of Second Event

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* Description/Outcome/Treatment of Second Event

Third Event

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* Third Event

Third Event Date

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* Third Event Date

Description/Outcome/Treatment of Third Event

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* Description/Outcome/Treatment of Third Event

Additional Comments

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* Additional Comments

Since treatment ended or last report have there been any significant life events such as marriage, pregnancy/parenthood?

If yes please use the spaces below to report each event
Events to report

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* Events to report

First Event

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* First Event

First Event Date

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* First Event Date

Description/Outcome of First Event

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* Description/Outcome of First Event

Second Event

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* Second Event

Second Event Date

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* Second Event Date

Description/Outcome of Second Event

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* Description/Outcome of Second Event

Third Event

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* Third Event

Third Event Date

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* Third Event Date

Description/Outcome of Third Event

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* Description/Outcome of Third Event

Additional Comments

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* Additional Comments

Participant offspring to report on?

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* Participant offspring to report on?

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