Attachment 4 Pre- and Post-Shift Red Tide Questionnaire 

                                                            Form Approved
                                                            OMB no. 0920-0494 
                                                            Exp. Date xx/xx/20xx  

DAY 1:  Pre-Shift

1. INTERVIEWER NAME				 ___________________

2.  DATE OF INTERVIEW				  ____/____/____
							  mm  dd  yyyy		

3.  TIME ___:___ am / pm

4.  LOCATION						______________________________
							STREET ADDRESS
							______________________________
							NAME OF BEACH
							______________________________
							CITY
							______________________________
							STATE, ZIP 
______________________________________________________________________________

Home Phone:	(_________) _________ ‑ _________________

Public reporting burden for this collection of information is estimated to vary from 15 to 25 minutes per response, with an average response of 20 minutes, 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; Paperwork Reduction Project (0920-0494); M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333

To begin this part of the interview, I have a few questions about your home and your job.

5.  Does your home have air conditioning?
							1.  NO (GO TO QUESTION 6)
							2.  YES (GO TO QUESTION 5a)
							88.  DON’T KNOW
							99.  REFUSED

	5a.  Are you using it regularly?			1.  NO
							2.  YES
							77. NA
							88.  DON’T KNOW
							99.  REFUSED

	5b.  Did you use your air conditioner last night?
							1.  NO
							2.  YES
							77. NA
							88.  DON’T KNOW
							99.  REFUSED

6.  What is your job title?				1.  LIFEGUARD
							2.  MARINE BIOLOGIST/
								RESEARCH ASSISTANT
							3.  OTHER
							     Specify __________________________
							88.  DON’T KNOW
							99.  REFUSED

7.  Counting the time you are at work and other times, about how many hours do you spend on the water during the average work week?
							1. __________ hours
							88.  DON’T KNOW
							99.  REFUSED

8.  When was the last time you were on the water while at work before today.
							1.  YESTERDAY
							2.  WITHIN THE LAST WEEK
							3.  WITHIN THE LAST MONTH
							4.  OTHER
							     Specify __________________________
							88.  DON’T KNOW
							99.  REFUSED

9.  About how many hours do you spend on the beach or close to shore during the average work week?							1. __________ hours
							88.  DON’T KNOW
							99.  REFUSED

10.  When was the last time you were on the beach or close to shore while at work before today?
							1.  YESTERDAY
							2.  WITHIN THE LAST WEEK
							3.  WITHIN THE LAST MONTH
							4.  OTHER
							     Specify __________________________								88.  DON’T KNOW
							99.  REFUSED

11.  Have you ever been on the water or on the beach or shore during a red tide?
							1.  NO (GO TO QUESTION 12)
							2.  YES (GO TO QUESTION 11a)
							88.  DON’T KNOW
							99.  REFUSED
	
	11a.  Did you have any symptoms or health problems during the red tide?
							1.  NO (GO TO QUESTION 12)
							2.  YES (GO TO QUESTION 11a1)
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

Can you tell me what your symptoms were and whether you felt they were mild, moderate, or severe?

		11a1. Cough		1.  NO			11a1a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a2. Wheezing		1.  NO			11a2a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a3. Throat irritation	
					1.  NO			11a3a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a4. Shortness of breath
				1.  NO			11a4a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a5. Chest heaviness or tightness
					1.  NO			11a5a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a6.  Nasal congestion
					1.  NO			11a6a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a7. Eye irritation/tearing
					1.  NO			11a7a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a8. Headache		1.  NO			11a8a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a9. Itchy skin		1.  NO			11a9a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a10. Diarrhea		1.  NO			11a10a.1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		11a11. Other		1.  NO			11a11a.1. MILD
					2.  YES			2. MODERATE
					      Specify			3.  SEVERE
				                    ____________	77.  NA
					77.  NA			88.  DON’T KNOW
					88.  DON’T KNOW		99.  REFUSED
					99.  REFUSED	
							
Now, I am going to ask you about a series of symptoms, and I’d like you to tell me if you are having the symptom now, and whether it is mild, moderate, or severe.
	
	12a1. Cough			1.  NO			12a1a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a2. Wheezing		1.  NO			12a2a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a3. Throat irritation	
					1.  NO			12a3a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a4. Shortness of breath
				1.  NO			12a4a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a5. Chest heaviness or tightness
					1.  NO			12a5a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a6. Nasal congestion
					1.  NO			12a6a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a7. Eye irritation/tearing
					1.  NO			12a7a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a8. Headache		1.  NO			12a8a.	1. MILD
					2.  YES			2. MODERATE
					3.  YES-UNRELATED	3. SEVERE
					77.  NA			77. NA
					88.  DON’T KNOW		88. DON’T KNOW	
					99. REFUSED			99. REFUSED

		12a9. Itchy skin		1.  NO			12a9a.	1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a10. Diarrhea		1.  NO			12a10a.1. MILD
					2.  YES			2. MODERATE
					77.  NA			3. SEVERE
					88.  DON’T KNOW		77. NA
					99.  REFUSED		88. DON’T KNOW
									99. REFUSED

		12a11. Other		1.  NO			12a11a.1. MILD
					2.  YES			2. MODERATE
					      Specify			3. SEVERE
					      ______________	77. NA
					77.  NA			88. DON’T KNOW
					88.  DON’T KNOW		99. REFUSED
					99.  REFUSED

Now, I need to ask you a few questions that will help us interpret the results of your pulmonary function tests.

13. Have you taken any medications, including allergy or asthma medicines, such as inhalers, antihistamines, or cough medicine today?
							1.  NO
							2.  YES
							88.  DON’T KNOW
							99.  REFUSED

14. Have you had a cold in the last three weeks?		1.  NO
							2.  YES
							88.  DON’T KNOW
							99.  REFUSED

15. Have you smoked a cigarette in the last hour?	1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

Now, just a few more questions about your height and weight:

16. Have you lost or gained 10 or more pounds in the last month?
							1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

17.  Height _________ inches

18.  Weight _________ pounds					

That is my last question for this part of the interview.  Now, we would like to have you do some pulmonary function tests.

 
                                                            Form Approved
                                                            OMB no. 0920-0494 
                                                            Exp. Date xx/xx/20xx  

DAY 1:  Post-Shift Red Tide Questionnaire

1.  INTERVIEWER NAME				 ___________________

2.  DATE OF INTERVIEW				  ____/____/____
							  mm  dd  yyyy		

3.  TIME ___:___ am / pm

4.  LOCATION					______________________________

					STREET ADDRESS
							______________________________
							NAME OF BEACH
							______________________________
							CITY
							______________________________
							STATE, ZIP 
______________________________________________________________________________

5.  At what time did you start your shift today?		____:_____ am / pm

6.  Since we talked this morning, about how many hours have you spend on the water?
							___________ HOURS
							88.  DON’T KNOW
							99.  REFUSED

7.  Since we talked this morning, about how many hours did you spend on the beach or near the shore?							___________ HOURS
							88.  DON’T KNOW
							99.  REFUSED

I am going to read a list of symptoms to you.  Would you please tell me if you had that symptom during your work day today, about when the symptom started, and about how long it lasted?
I also want to know if you thought the symptom was mild, moderate, or severe.

NOTE TO INTERVIEWERS:

	IF STUDY PARTICIPANT REPORTS THAT THEY EXPERIENCED A SYMPTOM, IT WENT AWAY, AND THEN RECURRED, PLEASE RECORD THE TIME AND SEVERITY INFORMATION FOR THE FIRST OCCURRENCE ANSWER YES TO QUESTION 8l.

	8a.  Cough				1.  NO
						2.  YES
							8a1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8a2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8a3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED		

	8b.  Wheezing				1.  NO
						2.  YES
							8b1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8b2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8b3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED

	8c.  Throat irritation			1.  NO
						2.  YES
							8c1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8c2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8c3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8d.  Shortness of breath			1.  NO
						2.  YES
							8d1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8d2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8d3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8e.  Chest heaviness or tightness		1.  NO
						2.  YES
							8e1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8e2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8e3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8f.  Nasal congestion			1.  NO
						2.  YES
							8f1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8f2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8f3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8g.  Eye irritation/tearing		1.  NO
						2.  YES
							8g1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8g2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8g3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8h.  Headache				1.  NO
						2.  YES
							8h1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8h2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED
		8h3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED

	8i.  Itchy skin				1.  NO
						2.  YES
							8i1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8i2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8i3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED	

	8j.  Diarrhea				1.  NO
						2.  YES
							8j1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8j2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8j3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED

	8k.  Other				1.  NO
						2.  YES
							8k4.  Specify ______________________
							8k1.  WHEN STARTED ___:___ am / pm
								77.  NA
							8k2.  HOW LONG DID SYMPT. LAST?
								__________ HOURS
								66.  ONGOING
								77.  NA
						77. NA
						88.  DON’T KNOW
						99.  REFUSED

		8k3.	1. MILD
			2. MODERATE
			3. SEVERE	
			77. NA
			88. DON’T KNOW
			99. REFUSED

	8l. 	SYMPTOMS RECURRED DURING THE SHIFT
		1. YES
		2. NA
		88. DON’T KNOW

		99. REFUSED

								
IF NO TO QUESTION 8, SKIP TO QUESTION 13

9.  Did your symptoms make you to stop working or performing your usual activities?
							1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

10.  Did your symptoms make you leave the area of the beach or shore?
							1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

11.  Did your symptoms get better when you left the area of the water OR (beach or shore)?
							1.  NO (GO TO QUESTION 12)
							2.  YES (GO TO QUESTION 11a)
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

	11a.  About how long did it take after leaving the area for your symptoms to get better?
							__________ hours
							66.  ONGOING
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

12.  Do you still have these symptoms?
							1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

13.  Did anyone you were with experience any of these symptoms today?
							1.  NO
							2.  YES
							88.  DON’T KNOW
							99.  REFUSED

Now, I need to ask you a few questions that will help us interpret the results of your pulmonary function tests.

14. Have you taken any medications, including allergy or asthma medicines, such as inhalers,
antihistamines, or cough medicine today?
							1.  NO
							2.  YES
							88.  DON’T KNOW
							99.  REFUSED

15. Have you had a cold in the last three weeks?		1.  NO
							2.  YES
							88.  DON’T KNOW
							99.  REFUSED

16.  Have you smoked a cigarette in the last hour?	1.  NO
							2.  YES
							77.  NA
							88.  DON’T KNOW
							99.  REFUSED

That is the end of this part of the interview.  Thanks very much for your help with this study.