1 Survey

Appendix A A.2.3.s–1

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Environmental Questions

EQ1. For this study, we will be collecting some environmental samples in your home.

EQ2. Is the tap water in your home from a private well?

YES 1

NO 2

REFUSED 9--97

DON’T KNOW 9--98

EQ3. Do you have any non-electric appliances in your home? We are interested in things like a stove or oven, furnace, water heater, dryer or a gas, oil, or kerosene space heater.

YES 1 (EQ007)

NO 2 (EQ007)

REFUSED 9--97 (EQ007)

DON’T KNOW 9--98

EQ4. Can you show me your stove and your heating system if it is accessible?

DATA COLLECTOR INSTRUCTION : RECORD WHETHER THE STOVE OR HEATING SYSTEM APPEAR TO BE GAS.

YES NO ACCESSIBLE RF DK

a. GAS/FUEL HEAT? 1 2 3 9--97 9—98

b. GAS/STOVE/OVEN? 1 2 3 9--97 9—98

EQ5. Is this a single family home?

YES, SINGLE FAMILY HOME 1

NO, MULTI-FAMILY HOME 2

REFUSED 9--97

DON’T KNOW 9--98

N ational Children’s Study

Dwelling Unit

Visual Observations

^{P1, T1-1st, T3-1st}

Time Started:

:

1AM 2PM

Staff ID:

H

H

H

H

H

Time Ended:

:

1AM 2PM

Questions for Participant

1. Bedrooms in home: __|__

2. Bathrooms in home: # full baths __|__ # HALF BATHS __

3. Can you show me the room where you sleep most of the time? TAKE VACUUM SAMPLE IN THIS ROOM

4. Can you show me the surface of the bed on which you sleep? By surface, I mean on which blanket or sheet do you sleep directly on top? VACUUM THIS SURFACE FOR BED PORTION OF SAMPLE

5. Can you show me the room you use the most? (IF SHE RESPONDS THAT SHE USES THE KITCHEN THE MOST, ASK HER FOR THE NEXT MOST USED ROOM)

Appliance Use
TECHNICIAN INSTRUCTIONS: Mark all appliances SP reports having in her home. If the appliance is present, ask the frequency of use, then inspect the venting and the pilot light.
Do you have any of the following …?	# in DU	Frequency of use: 1 = Daily 2 = Every other day 3 = 2 times a week 4 = < 2 times a week	# Vented	# Cont. pilot
6. Dehumidifier	__ 8 DK	__ 8 DK	NA	NA
7. Humidifier	__ 8 DK	__ 8 DK	NA	NA
8. Air cleaning device, Type(s): Mark all. 2 Electrostatic precipitator 3 Ozone generator 4 Filter 6 Other, Brand: 1234567890 Model #:1234567890	__ 8 DK	__ 8 DK	NA	NA
9. Gas stovetop or range top:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
10. Gas oven (include convection ovens):	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
11. Gas or fuel furnace:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
12. Any special ventilation systems: 1 Fresh air / heat exchanger 6 1234567890\	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
13. Gas hot water heater:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
14. Dryer: Electric	__ 8 DK	__ 8 DK	__ 8 DK	NA
Gas	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
15. Propane/ kerosene/ gas space heater:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
16. Gas fireplace or stove:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
17. Wood/pellet-burning fireplace/stove:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
18. Coal-burning stove:	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK
19. Other combustion source: 1234567890123456	__ 8 DK	__ 8 DK	__ 8 DK	__ 8 DK

Product Use
TECHNICIAN INSTRUCTIONS: Mark if the products are present in the home. If the product is present ask the SP about the frequency of use.
Mark all.	Frequency of use: 1 = Daily 3 = 2 times a week 2 = Every other day 4 = < 2 times a week
20. Scented candles	__ 8 DK
21. Unscented candles	__ 8 DK
22. Incense	__ 8 DK
23. Room air fresheners, e.g., Plug-ins, stick-ups	__ 8 DK
24. Other scented household products: 1234567890	__ 8 DK

General Dwelling Unit Observations

24. Level lowest living area in DU (0=basement): _ |__|__ 25. DU floor: _ |__|_ NA (single family home) 26. General structural condition of DU: 1 Good (Go to 28) 2 Fair 3 Poor 27. Why condition not good: 1 Cracks on walls 2 Loose flooring, steps, rails, etc. 3 Paint chipping, peeling, etc. 4 Worn carpet 6 1234567890 28. Exit doors sealed tightly: 1 Yes 2 No 8 Don’t know 29. Window weatherproofing: Mark all. 1 Double pane 4 None 2 Storm windows 6 1234567890 3 Shrink film

30. Home cleanliness: 1 Very clean (Go to32) 3 Not clean 2 Mod. clean 31. Source of non-cleanliness: Mark all. 1 Dust 4 Stained carpet 2 Grime/grease 5 Animal hair 3 Food 6 1234567890 32. Household clutter: 1 Little 2 Mod. cluttered 3 Very cluttered 33. Evidence of cigarettes/smoking: 1 Yes 2 No 34. Observed type of heating system: Mark all. 1 None 4 Space heaters 2 Forced air (vents)6 1234567890 3 Radiators (any type) 35. Comments: 1 None 6 1234567890

Revised 7/18/08

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.