Exam 6. / / Month Day Year. Lung CT With Contrast Protocol: FORCE Comple on Form. Acros c: Par cipant ID #: Date: Technician ID: SECTION A: Screening

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1 SECTION A: Screening 1. Did par cipant consent to the lung CT? Par cipant ID #: Technician ID: Date: Acros c: / / Month Day Year STOP. Do not perform any CT scan. Refused (a er consen ng) STOP. Do not perform any CT scan. 2. Did par cipant consent to contrast? Refused STOP. Skip to Sec on C n Contrast protocol. STOP. Skip to Sec on C n Contrast protocol. 3. Did par cipant pass the Lung contrast screener? STOP. Skip to Sec on C n Contrast protocol. 4. Can the par cipant keep their arms above their head for the CT scan? STOP. Skip to Sec on C n Contrast protocol. Page 1 of 6

2 5. Was egfr test performed? Pending (t eligible for contrast if egfr not done) Wait for result Date of crea nine measurement: / / Month Day Year Indicate reason: Refused Par cipant Age: Serum crea nine:. Gender: Male Female Race: Using the following website: h p://touchcalc.com/e_gfr Enter the crea nine, age, gender, and race above to calculate the GFR: blood for test Ill Physically unable STOP. Skip to Sec on C n Contrast protocol. Calculated GFR value: If GFR 60 If GFR < 60 STOP. Skip to Sec on C n contrast protocol 6. Are you able to administer contrast? to Sec on B contrast protocol Indicate reason and then skip to Sec on C n contrast protocol Unable to obtain IV Pump malfunc on Page 2 of 6

3 SECTION B: Contrast CT Scanning Protocol (1 non contrast scan and 1 contrast scan) START OF SECTION B Scan 1: n contrast CT at full inspira on (TLC) Is actual DLP more than 125 mgy*cm? to Scan 2 Do not perform Scan 2. Skip to sec on C. Scan 2: Contrast CT at relaxed exhala on (FRC) A er scan length is set from topogram, FRC es mated DLP: Is es mated DLP more than 300 mgy*cm? Perform scan Add FRC Es mated DLP to TLC Actual DLP Is sum of the two DLP more than 425 mgy*cm? Perform scan Do not perform Scan 2. Skip to sec on C. Quality of performed scans: Followed breathing instruc ons for all performed scans Mo on ar fact on any performed scan Inclusion of whole lung on all performed scans Page 3 of 6

4 Alarm findings (e.g., large mass, large effusion): If yes, describe: Unexpected event:, specify: Fain ng episode Allergic reac on suspected END OF SCANNING. END OF STUDY. DO NOT COMPLETE SECTION C. SECTION C: n Contrast CT Scanning Protocol (3 non contrast scans) START OF SECTION C *Cau on: Do NOT complete this sec on if par cipant performed ALL of Sec on B* Was the non contrast CT at full inspira on (TLC) already performed during Contrast Protocol? to Scan 1 Is actual DLP more than 200 mgy*cm? Skip to Scan 2 DO NOT CONTINUE. END OF STUDY. Page 4 of 6

5 Scan 1: n contrast CT at full inspira on (TLC) Is actual DLP more than 200 mgy*cm? to Scan 2 DO NOT CONTINUE. END OF STUDY. Scan 2: n contrast CT at relaxed exhala on (FRC) Is actual DLP more than 100 mgy*cm? to Scan 3 DO NOT PERFORM SCAN 3. SKIP TO QUALITY OF PERFORMED SCANS Scan 3: n contrast CT at full exhala on (RV) Quality of performed scans: Followed breathing instruc ons for all performed scans Mo on ar fact on any performed scan Inclusion of whole lung on all performed scans Page 5 of 6

6 Alarm findings (e.g., large mass, large effusion): Unexpected event:, specify: If yes, describe: Fain ng episode END OF SECTION C DO NOT COMPLETE SECTION B Page 6 of 6