TRAINING ONLY: 3-Month Post Scan Telephone Survey (#6)

THIS FORM WILL BE COMPLETED VIA TELEPHONE WITH SUBJECTS WHO HAD A SUSPECTED RUPTURE BASED ON SC

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* 1. STUDY SITE NUMBER: (enter the assigned number for your site)

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* 2. Subject Initials (2 characters)

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* 3. Confidential Subject ID (3 Numbers)

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* 4. Interviewer Last Name

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* 5. Since your ultrasound scan about 3 months ago showed a suspected rupture of your implant(s), what action (if any) have you taken? (check all that apply)

I have taken no action

I had an MRI scan that confirmed the rupture

I had an MRI scan that did not confirm the rupture

I had a 2nd high resolution ultrasound scan that confirmed the rupture

I had a 2nd high resolution ultrasound scan that did not confirm the rupture

I saw another plastic surgeon for a 2nd opinion

I have decided not to have surgery

I am planning to have surgery or already had surgery (please answer next two questions)