Attachment F2. Example Site-Specific Survey

Attachment F2. Overview of a Sample Data Collection Instrument This document illustrates how questionnaire items can be selected from the pre-approved reference modules and combined to produce a site-specific evaluation instrument. For the reviewer’s convenience, key features of the example are summarized in the table below. The remainder of this attachment consists of an example data collection instrument.
Summary of Instrument Design
Site:	Park Hills, Missouri
Contaminant Group:	Metals
Environmental Media:	Soil, Water, Biota
Pathway:	Oral, Dermal, Inhalation
Data collection plan:	Baseline assessment
Data collection method:	Interviewer-assisted
Summary of Instrument Contents
Cover Page:	Communicates required advisements to respondents including OMB approval and burden information as well advisements required by the Privacy Act
Section 1:	Data collection items selected from Attachment N, Questionnaire Items for Assessing General Knowledge and Opinions Module
Section 2:	Data collection items selected from Attachment F3, Contaminant Group, Environmental Media, and Environmental Pathway Module (CEEPM) Module
Section 3:	Data collection items selected from Attachment E4, Intention to Change Module
Section 4:	Data collection items selected from Attachment E1, Demographics Module

Form Approved

OMB No. 0923-XXXX

Expiration Date: xx/xx/xx

Park Hills Household Survey

You have been chosen to answer this survey because you are a member of this community. The questions take about twenty (20) minutes to complete.

The name of this survey is the Park Hills Household Survey. It is authorized under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), Section 104(i) – also known as the Superfund.

I’d like to ask you some questions about your day-to-day activities, knowledge and beliefs about the environment, and some characteristics about you and your household.

You don’t have to answer any question you don’t want to, and you can end the interview at any time. Any information that you give me will be kept confidential. Data collected will not be disclosed in identifiable form to anyone but authorized staff conducting the survey or as provided by law.

If you have any concerns about your rights as a survey participant or any questions about this survey, I will provide you a telephone number for you to call to get more information.

May I begin?

_____________________________________________________________

Public reporting burden of this collection of information is estimated to average 20 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)

Section 1

[Read the following statement to the respondent]

I am going to read a few statements about some types of environmental hazards that communities such as yours might experience. Please tell me how much you feel each of the following are a problem in your community. Are any one of these environmental hazards “a very big problem,” “somewhat of a problem,” “somewhat not a problem,” or “not at all a problem” in your community? [Hand respondent correct response card]

	A very big problem	Somewhat of a problem	Somewhat not a problem	Not at all a problem	Don’t know
EHC-1. Indoor air quality	1	2	3	4	5
EHC-2. Outdoor air quality	1	2	3	4	5
EHC-3. Safety of water for drinking	1	2	3	4	5
EHC-4. Safety of water for recreational use (such as fishing, swimming, canoeing, boating)	1	2	3	4	5
EHC-5. Safety of food grown locally	1	2	3	4	5
EHC-6. Safety of fish caught locally	1	2	3	4	5
EHC-7. Environmental hazards in your home	1	2	3	4	5
EHC-8. Environmental hazards in your workplace	1	2	3	4	5
EHC-9. Environmental hazards in local schools	1	2	3	4	5
EHC-10. Environmental hazards in recreational areas such as playgrounds and parks	1	2	3	4	5

[Read the following statement to the respondent]

I am next going to read you a few statements about environmental hazards in general and in your community. Please tell me how strongly you agree or disagree with each statement. That is, do you “strongly agree,” “agree somewhat,” “disagree somewhat,” or “strongly disagree” with the statement about environmental hazards. [Hand respondent correct response card]

	Strongly Agree	Agree Somewhat	Disagree Somewhat	Strongly Disagree	Don’t know
An environmental hazard can only make you sick if you are exposed	1	2	3	4	5
It may take years of exposure to an environmental hazard to become sick	1	2	3	4	5
My family and I are at risk because of environmental hazards in our area	1	2	3	4	5
You can get cancer from exposure to environmental hazards	1	2	3	4	5
Environmental hazards can cause serious health problems	1	2	3	4	5

[Read the following statement to the respondent]

Next I am going to read to you some statements about contaminants in general and in your community. Using the same response categories as before, please tell me how strongly you agree or disagree with each statement. That is, do you “strongly agree,” “agree somewhat,” “disagree somewhat,” or “strongly disagree” with the following statements. [Hand respondent correct response card]

	Strongly Agree	Agree Somewhat	Disagree Somewhat	Strongly Disagree	Don’t know
I know where site contaminants are located in my community	1	2	3	4	5
I know the ways in which the contaminants could get in my body	1	2	3	4	5
I know how exposure to contaminants could effect my health	1	2	3	4	5
I know what actions I can take to keep me and my family safe	1	2	3	4	5

Section 2

These next items ask about some of the day-to-day activities of you and your household. In the past 6 months please tell me how often you do each one. That is, for each activity, would you say that you “never do this,” “seldom do this,” “sometimes do this,” or “always do this.”

[Hand respondent correct response card]

	Never Do This	Seldom Do This	Sometimes Do This	Always Do This	Don’t Know/ Not Applicable
1. Avoid outdoor activity such as working, playing, gardening, and yard work during very windy days	1	2	3	4	5
2. Change clothes soon after outdoor activity such as working, playing, gardening, and yard work	1	2	3	4	5
3. Clean shoes before entering house	1	2	3	4	5
4. Damp dust home rather than dry dust	1	2	3	4	5
5. Follow posted signs	1	2	3	4	5
6. Remove shoes before entering home	1	2	3	4	5
7. Use a vacuum with a bag (not a bagless vacuum, shop vac, or steam cleaner)	1	2	3	4	5
8. Use a vacuum with a HEPA filter	1	2	3	4	5
9. Use containers or raised beds for gardening	1	2	3	4	5
10. Vacuum home once a week or more often	1	2	3	4	5
11. Drink unfiltered water from creeks, streams, or rivers	1	2	3	4	5
12. Walk, jog, or bicycle on the site	1	2	3	4	5
13. Wash fruits and vegetables before eating	1	2	3	4	5

14. Wash hands, face, and other exposed skin soon after outdoor activity such as playing, gardening, yard work, and other outdoor work	1	2	3	4	5
15. Wear gloves when working in soil doing gardening, digging, building, and other activities	1	2	3	4	5
16. Wear long sleeves and pants during outdoor activity such as playing, gardening, yard work, and other outdoor work	1	2	3	4	5
17. Wet mop home once a week or more often	1	2	3	4	5
18. Work in soil at home through gardening, digging, building, repairing and other outside activities	1	2	3	4	5
19. Wash dirty clothes soon after wearing outdoors	1	2	3	4	5
The Missouri Department of Health and Senior Services has issued a 2005 Fish Consumption Advisory for lead. The advisory reads as follows “Do not consume certain fish species found in the Big River in St. Francois and Jefferson Counties, the Flat River in St. Francois County from Highway “B”, six miles downstream to where it enters the Big River, and sunfish from Big Creek near the town of Glover in Iron County, Missouri.” In the past six months, how often would you say that you………
20. Follow fish consumption advisories	1	2	3	4	5

21. Ask if there are children currently in the home. If yes, continue. If no, please skip to the next section. _____1. Yes _____2. No [SKIP to next section] Using the same response categories as before, please tell me in the past 6 months how often would you say that you ……….
22. Keep children from biking, playing, or doing other activities in areas of concern	1	2	3	4	5
23. Keep children from crawling or playing on the floor	1	2	3	4	5
24. Keep children from playing, climbing, running, digging, or doing other activities on the site	1	2	3	4	5
25. Keep children from riding ATVs or motorized bikes on the site	1	2	3	4	5
26. Keep children from thumb sucking and nail biting	1	2	3	4	5
27. Keep children from walking or bicycling on the site	1	2	3	4	5
28. Periodically damp wash children's play areas	1	2	3	4	5
29. Wash children’s face, hands, and other exposed skin soon after outdoor play	1	2	3	4	5
30. Wash children's face and hands before they eat or drink	1	2	3	4	5
31. Wash children's toys	1	2	3	4	5

Section 3

We have just a few more questions to complete this interview.

I am now going to read one or more statements. Please let me know whether you “Agree” or “Don’t agree” with the statement.

1. Changing my behavior to limit or reduce potential exposure to contaminants in my community has become routine.

_____Agree [Stop, skip to next section]

_____Don’t agree

2. I have taken the recommended actions to limit potential exposure to contaminants in my community.

_____Agree [Stop, skip to next section]

_____Don’t agree

3. I have recently started taking steps to limit potential exposure.

_____Agree [Stop, skip to next section]

_____Don’t agree

4. I plan to do something different in the next six months in order to reduce potential exposure.

_____Agree [Stop, skip to next section]

_____Don’t agree

5. I do not plan to change anything I do in order to reduce my or members of my household’s potential exposure.

_____Agree

_____Don’t agree

Section 4

This is the last section of the questionnaire and it asks a few questions about yourself and your household.

1. What is your age?

_______ Years

2. Are you Hispanic or Latino?

_____1. Yes

_____2. No

_____3. Don’t know / Not sure

3. Which one or more of the following would you say is your race? [Read choices]

_____1. White

_____2. Black or African American

_____3. Asian

_____4. Native Hawaiian or Other Pacific Islander

_____5. American Indian or Alaska Native

_____6. Don’t know / Not sure

4. What is your marital status? [Read choices only if necessary]

_____1. Married

_____2. Divorced

_____3. Widowed

_____4. Separated

_____5. Never married

_____6. A member of an unmarried couple

5. What is your sex? [DO NOT ASK – record answer]

_____1. Male (SKIP to question 7)

_____2. Female

6. To your knowledge, are you now pregnant?

_____1. Yes

_____2. No

_____3. Don’t know / Not sure

7. How many children less than 18 years of age live in your household?

­_________ Number of children

8. What is the highest grade or year of school you completed? [Read choices only if necessary]

_____1. Never attended school or only attended kindergarten

_____2. Grades 1 through 8 (Elementary school)

_____3. Grades 9 through 11 (Some high school)

_____4. Grade 12 or GED (High school graduate)

_____5. College 1 year to 3 years (Some college or technical school)

_____6. College 4 years of more (College graduate)

9. What is your current employment status? Are you currently …… [Read choices]

_____1. Employed for wages

_____2. Self-employed

_____3. Out of work for more than 1 year

_____4. Out of work for less than 1 year

_____5. A Homemaker

_____6. A Student

_____7. Retired

_____8. Unable to work

10. What is your annual household income from all sources? Would you say it is … [Read choices]

_____1. Less than $10,000

_____2. $10,000 to less than $15,000

_____3. 15,000 to less than $20,000

_____4. $20,000 to less than $25,000

_____5. $25,000 to less than $35,000

_____6. $35,000 to less than $50,000

_____7. $50,000 to less than $75,000

_____8. $75,000 or more

_____9. Don’t know / Not sure

11. How long have you lived at your current residence?

________ years

________ Don’t know / Not sure

12. When was your house built?

________ year (example: 1965)

________ Don’t know / Not sure

13. Have you smoked at least 100 cigarettes in your entire life?

Note: 5 packs = 100 cigarettes

_____ 1. Yes

_____ 2. No [SKIP to question 15]

_____ 3. Not sure / Don’t know

14. Do you now smoke cigarettes every day, some days, or not at all?

_____1. Everyday

_____2. Some days

_____3. Not at all

15. What is your current address?

Name___________________________________________________________

Street Address ______________________________________ Apt # ________

City _______________________ State __________ Zip Code______________

That is the end of the survey. I want to thank you for your time and participation in this survey.

Do you have any questions for me?

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