1 Survey

Appendix A A.2.3.r–3

National Children’s Study

2 4 Mo – Pesticide wipe QUESTIONNAIRE

DRAFT ONLY – NOT FOR DISTRIBUTION

• Use only a black, ball-point pen. Do not use a pencil or felt-tip pen.

• Put an X in the box next to your answer.

• If you make any changes, put a line through the incorrect answer  and put an X in the box next to the correct answer. Also, draw a circle around the correct answer .

1. Please record the date you collected the wipes:

MONTH	DAY		YEAR
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	0	0	2008 2009 2010 2011 2012 2013 2014 2015
	1	1
	2	2
	3	3
		4
		5
		6
		7
		8
		9

2. In which room were the two wipes taken:

₁ Family or living room

₂ Your child’s bedroom

₃ Kitchen

₆ Other, specify: ___________________

3. What type of surface did you wipe when you collected Pesticide Wipe 1?

₁ Tile or Linoleum

₂ Wood floor

₃ Room-sized rug or wall-to-wall carpet

₄ Small area rug

₆ Other, specify: ___________________

4. What type of surface did you wipe when you collected Pesticide Wipe 2?

₁ Tile or Linoleum

₂ Wood floor

₃ Room-sized rug or wall-to-wall carpet

₄ Small area rug

₆ Other, specify: ___________________

5. Did you run into any problems when taking the pesticide wipes?

₀ No (SKIP TO QUESTION 7)

₁ Yes

5a. Which wipe did you run into problems with?

₁ Pesticide Wipe 1

₂ Pesticide Wipe 2

₃ Both Pesticide Wipes

5b. What problems did you have when collecting the wipe(s)?

₁ Wipe ripped, Wipe 1

₂ Wipe ripped, Wipe 2

₃ Could not wipe the entire area, Wipe 1

₄ Could not wipe the entire area, Wipe 2

₅ Wiped outside the area, Wipe 1

₆ Wiped outside the area, Wipe 2

₉₆ Other, specify: __________________

Thank you very much for completing this questionnaire! All of your answers are very important.

DRAFT ONLY – NOT FOR DISTRIBUTION