Form No number No number TAR Adult and Child Baseline Surveys
Tremolite Asbestos Registry
Appendix D (Baseline Surveys)
Tremolite Asbestos Registry - Baseline Surveys
OMB: 0923-0039
Appendix D
TAR Adult and Child Baseline Surveys
OMB #0923-0039
Expires:
OMB #0923-0039
Expires:
For Office Use Only
Interviewer: _________________
Date: _______________
Start: _______________
Stop: _______________
ADULT BASELINE
DEMOGRAPHICS/RESIDENTIAL HISTORY
Please tell me your full name : (a) First ________ (b) Middle _________ (c) Last ______
Please tell me your date-of-birth: (a) ________ Month (b) ________ Day (c) _______Year
What is your Social Security number? _________
Sex __________________
Which of the following categories best describes your racial background?
Black or African American
White
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Other
If other, please specify your racial background:_____________
Are you Hispanic or Latino (of Spanish origin or descent)? Yes No
Please tell me the addresses that you have lived at in the Libby area or Kootenai Valley area beginning with your current address:
Address 1: (a) ___________________________________________________________________
Time Period: From __________ To __________
Address 2: (b) ___________________________________________________________________
Time Period: From __________ To __________
Address 3: (c) ___________________________________________________________________
Time Period: From __________ To __________
Address 4: (d) ___________________________________________________________________
Time Period: From __________ To __________
Address 5: (e) ___________________________________________________________________
Time Period: From __________ To __________
OCCUPATIONAL HISTORY
Were you ever employed for pay outside the home? Yes No
If “No,” please skip to question 21
Did you ever work for W. R. Grace or Zonolite? Yes No
If “No,” please skip to question 17
What year were you first employed by W.R. Grace or Zonolite?
Year
Started
What year were you last employed by W.R. Grace or Zonolite?
Year
Started
Please tell me the job titles you had and the departments you worked in while you worked at W.R. Grace or Zonolite. Start with the first job you held and end with the last job you held.
Job Title
What department was that in?
What were your main activities or duties in this job?
What year did you start?
What year did you end?
How often did you use any type of respiratory protection (for example, a dust mask) while working at W.R. Grace or Zonolite?
Never Sometimes Frequently
How often did you shower or change clothes before leaving work?
Never Sometimes Frequently
How often did you wear your work clothes home from work?
Never Sometimes Frequently
How often did you use the household car to go to and from work?
Never Sometimes Frequently
Did you ever work as a secondary contractor to the mining or processing facilities, for example, as a truck driver, delivery person, or janitorial worker, etc?
Yes No
If “No,” please skip to question 18
If ”Yes,” please list below.
Please tell me the job titles you had working as a secondary contractor to the mining or processing facilities. Start with the first job you held and end with the last job you held.
Job Title
What were your main activities or duties in this job?
What year did you start?
What year did you end?
Have you had jobs, not including ones at W.R. Grace or Zonolite, in which you were exposed to a lot of dust (for example, foundry work, mining, or sandblasting)?
If “No,” please skip to question 19.
If ”Yes,” please list below.:
Please tell me the job titles, not including W. R. Grace or Zonolite in which you were exposed to a lot of dust. Start with the first job you held and end with the last job you held.
Job Title
What were your main activities or duties in this job?
What year did you start?
What year did you end?
Have you had jobs, not including ones at W.R. Grace or Zonolite, in which you may have been exposed to vermiculite (for example, insulation installer, logger near the mine, etc)?
If ”No,” please skip to question 20.
If “No,” please list below
Please tell me the job titles, not including W. R. Grace or Zonolite in which you were exposed to a lot of vermiculite. Start with the first job you held and end with the last job you held.
Job Title
What were your main activities or duties in this job?
What year did you start?
What year did you end?
Have you had jobs, not including ones at W.R. Grace or Zonolite, in which you worked:
…as a pipe or steam fitter?
…as a plumber?
…as a brake repair person?
…as an insulator
…as a dry wall finisher
…as a carpenter?
…as a roofer
…as an electrician
…as a welder
…in a job where you mixed, cut or sprayed asbestos material?
…in a shipyard, or performed ship construction or repair?
…in any job where you may have been exposed to asbestos?
…around anyone performing one of the jobs above?
Yes No
IF NO TO ALL OF THE ABOVE, SKIP TO QUESTION 21.
IF YES TO ANY OF THE ABOVE, PLEASE LIST EACH JOB BELOW:
Please tell me the job titles. Start with the first job you held and end with the last job you held.
Job Title
What were your main activities or duties in this job?
What year did you start?
What year did you end?
MILITARY SERVICE HISTORY
Were you ever in a military service?
Yes No
If ”No,” please skip to question 22.
In the military, did you ever work on any kind of ship?
Yes No
If yes, please describe your duties:___________________________________
Are you aware of any exposure to asbestos during your military service?
Yes No
If yes, please describe how you may have been exposed:_________________
HOUSEHOLD CONTACT HISTORY
Did you ever live with someone while they worked for W.R. Grace or Zonolite? Yes No
If “No,” please skip to question 32
a. Name: b. Name: c. Name:
What is (INSERT NAME) relationship to you?:
a. Relation: b. Relation: c. Relation:
How long did you live with (INSERT NAME)?:
a. Years: b. Years: c. Years:
How many of the years that you lived with (INSERT NAME) did ( INSERT NAME) work for W.R. Grace or Zonolite?
a. Years: b. Years: c. Years:
What job did (INSERT NAME) do at W.R. Grace or Zonolite?
a. Job: b. Job: c. Job:
How often did (INSERT NAME a, b, or c) wear his or her work clothes home?
Never Sometimes Frequently
How often did you do the laundry for (INSERT NAME a, b, or c)?
Never Sometimes Frequently
How often did you visit (INSERT NAME a, b, or c) while he/she was at work?
Never Sometimes Frequently
How often did (INSERT NAME a, b, or c) use the household car for work transportation?
Never Sometimes Frequently
POTENTIAL ENVIRONMENTAL EXPOSURES
To your knowledge, is vermiculite insulation present at any of the Lincoln County, Montana addresses you provided?
Yes No
If YES, specify residence___________________________
Some products for the home, such as floor tiles, pipe insulation and siding can contain asbestos. Are you aware of any asbestos-containing products other than vermiculite that were present, or are still present, at any of the Lincoln County, Montana addresses you provided?
Yes No
If YES, specify asbestos-containing product and residence___________________________
Did you ever use vermiculite from the mine/plant for gardening?
Yes No
If YES, specify residence___________________________
Did you ever use vermiculite around one of the Lincoln County, Montana addresses you provided for any other purpose?
Yes No
If YES, specify purpose and residence___________________________
How often did you handle vermiculite insulation?
Never Sometimes Frequently
How often did you participate in recreational activities (hiking, hunting, etc.) along Rainy Creek Road?
Never Sometimes Frequently
How often did you play at the ball fields near the expansion plant?
Never Sometimes Frequently
How often did you play in or around the vermiculite piles?
Never Sometimes Frequently
If YES, where were these piles located?___________________________
How often did you heat vermiculite ore to make it expand or pop?
Never Sometimes Frequently
How often did you participate in activities where you came into contact with vermiculite insulation, products, or ores not mentioned above?
Never Sometimes Frequently
If YES, please specify:___________________________
TOBACCO USE
Have you ever smoked cigarettes? This means at least 400 cigarettes or 20 packs during your whole life.
Yes No
If “No,” please skip to question 48.
Do you now smoke cigarettes (as of one month ago)? Yes No
How old were you when you first started smoking regularly? Age in years
If you have stopped smoking completely, how old were you when you stopped? Age in years
How many cigarettes do you now smoke per day? Cigarettes/day
On the average over the entire time you smoked, how many cigarettes did you smoke per day? Cigarettes/day
Have you ever smoked a pipe regularly? (Yes means more than 12 oz of tobacco in a lifetime.) Yes No
If “No,” please skip to question 54.
How old were you when you started to smoke a pipe regularly? Age in years
If you have stopped smoking a pipe completely, how old were you when you stopped? _________________________________________________________________Age in years
On the average over the entire time you smoked a pipe, how much tobacco did you smoke per week? ________ oz/week
How much pipe tobacco are you smoking now? oz/week
Do you or did you inhale pipe smoke? Yes No
Have you ever smoked cigars regularly? Yes No
(Yes means more than 1 cigar for a week for a year in a lifetime.)
If “No,” please skip to question 60.
How old were you when you started to smoke cigars regularly? Age in years
If you have stopped smoking cigars completely, how old were you when you stopped?
_________________________________________________________________Age in years
On the average over the entire time you smoked cigars, how many cigars did you smoke per week? Cigars/week
How many cigars are you smoking per week now? Cigars/week
Do you or did you inhale cigar smoke? Not at all/Slightly/Moderately/Deeply
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff? Yes No
If “No,” Please skip to question 63.
While using smokeless tobacco, how many cans or pouches of tobacco do or did you use per week? ________________________________________________________________Containers/week
Do you currently use smokeless tobacco products every day, some days, or not at all?
____________________________________________________Every day/Some days/Not at all
Did any member of your family or household regularly smoke cigarettes inside the residence during the time that you lived together? Check yes for each person listed below.
IF YES, please indicate how many years you lived in the same household with them while they were smoking inside the residence.
Mother Yes No Years
Father Yes No Years
Spouse Yes No Years
Other Yes No Years
Other Yes No Years
Other Yes No Years
Are you currently living with someone who smokes inside the residence?
Yes No
MEDICAL/SYMPTOM HISTORY
Do you have a regular doctor or clinic that you go to?
Name
Address
Asbestos-Related Disease
Has your doctor ever told you that you had or treated you for asbestosis? If yes,
When were you were first treated for asbestosis?
Are you currently receiving treatment for asbestosis?
Were you hospitalized for asbestosis?
Has your doctor ever told you that you had or treated you for lung cancer? If yes,
When were you were first treated for lung cancer?
Are you currently receiving treatment for lung cancer?
Were you hospitalized for lung cancer?
Has your doctor ever told you that you had or treated you for mesothelioma? If yes,
When were you were first treated for mesothelioma?
Are you currently receiving treatment for mesothelioma?
Were you hospitalized for mesothelioma?
Cough
Do you usually have a cough? Yes No
(Count a cough with first smoke or on fist going out-of-doors. Exclude clearing of the throat.)
If “No,” please skip to 70.
Do you usually cough as much as 4 to 6 times a day, 4 or more days out of the week?
Yes No
Do you usually cough at all on getting up, or first thing in the morning?
Yes No
Do you usually cough at all during the rest of the day or night?
Yes No
IF YES TO ANY OF THE ABOVE, ANSWER THE FOLLOWING:
Do you usually cough like this on most days for 3 consecutive months or more during the year? Yes No
For how many years have you had this cough? Years
Phlegm
Have you ever coughed up phlegm (thick mucous) that was bloody?
Yes No
IF YES, ask:
In the past year have you coughed up phlegm that was bloody? Yes No
Do you usually bring up phlegm from your chest? Yes No
(Count phlegm with the first smoke or on first going out-of-doors. Exclude phlegm from the nose. Count swallowed phlegm.)
If “No” please skip to 77.
Do you usually bring up phlegm like this as much as twice a day, 4 or more days out of the week?
Yes No
Do you usually bring up phlegm at all on getting up, or first thing in the morning?
Yes No
Do you usually bring up phlegm at all during the rest of the day or at night?
Yes No
IF YES TO ANY OF 75-78, ANSWER THE FOLLOWING:
Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?
__________________________________________________________Yes No
For how many years have you had trouble with phlegm? Years
Episodes of cough and phlegm
Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year? *(For persons who usually have cough and/or phlegm.)
IF YES:
For how long have you had at least 1 such episode per year? Years
Other Medical/Symptom History
Have you ever had tuberculosis? Yes No
Have you ever been hospitalized for pneumonia or pleurisy? Yes No
Have you ever had congestive heart failure or fluid on the lungs? Yes No
Have you ever had any other chest illness? Yes No
Have you ever had a significant chest injury? Yes No
Have you ever had chest surgery (open heart or chest drainage tube)? Yes No
Do you suffer from rheumatoid arthritis, scleroderma, or lupus? Yes No
Have you ever had or do you now have any type of cancer? Yes No
IF YES, Please specify the type of cancer:_____
b. IF YES, Please specify the year of diagnosis:_______
Have you ever had chest x-ray? Yes No
IF YES, What year did you have your most current chest x-ray? Year
IF YES, Where was this x-ray taken? Clinic and city:
Have you ever been told by a doctor that you have a lung disease or condition?
Yes No
IF YES, What kind(s) of lung condition(s)?
IF YES, When were you told about it?
IF YES, Who told you about the problem? Dr.____
Have you become hoarse or developed difficulty swallowing in the last year?
Yes No
In the past year, have you had periods of chest pain related to breathing?
Yes No
Have you lost more than 15 pounds without dieting over the past 6 months?
Yes No
Are you now troubled by shortness of breath when walking up a slight hill or when hurrying on level ground? Yes No
Do you have to walk slower than people your own age because of shortness of breath? Yes No
Do you have to stop for breath when walking at your own pace on level ground? __________________________________________________Yes No
Do you have to stop for breath when walking about 100 yards (or after walking several minutes) on level ground? Yes No
Are you too short of breath to leave the house, or are you short of breath while dressing or undressing? Yes No
O
THER
INFORMATION
How concerned or worried are you that there is something in your neighborhood environment that may be harming your health? Not at all/A little/Very
We may ask to interview you again in the future to check up on your health status. Keeping in mind that people move, we would like to get a little more information to help us locate you in the future. Could we have the addresses of two people who live outside of your household and who would always know how to find you? Yes No
IF YES:
Contact #1: Name/Phone Number/Address/Relationship
Contact #2: Name/Phone Number/Address/Relationship
Are there any comments you would like to add or any important information that you think we should know?:_____________________
Interviewer comments:________________
Thank you for participating.
OMB #0923-0039
Expires:
For Office Use Only
Interviewer: _________________
Date: _______________
Start: _______________
Stop: _______________
CHILD BASELINE
DEMOGRAPHICS/RESIDENTIAL HISTORY
Please tell me your full name: (a) First _______ (b) Middle _________ (c) Last ______
What is your relationship to the child: ____________
Please tell me your child’s full name: (a) First _______ (b) Middle _________ (c) Last ______
Please tell me [CHILD NAME] date-of-birth: (a) _____ Month (b) ______ Day (c) _____Year
What is [CHILD NAME] Social Security number?_________
What is [CHILD NAME] Sex? __________________
Which of the following categories best describes your child’s racial background?
Black or African American
White
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Other
If other, please specify your racial background:_____________
Is your Hispanic or Latino (of Spanish origin or descent)? Yes No
Please tell me the addresses that [CHILD NAME] has lived at in the Libby area or Kootenai Valley beginning with [CHILD NAME] current address:
Address 1: (a) ___________________________________________________________________
Time Period: From __________ To __________
Address 2: (b) ___________________________________________________________________
Time Period: From __________ To __________
Address 3: (c) ___________________________________________________________________
Time Period: From __________ To __________
Address 4: (d) ___________________________________________________________________
Time Period: From __________ To __________
Address 5: (e) ___________________________________________________________________
Time Period: From __________ To __________
HOUSEHOLD CONTACT HISTORY
Did [CHILD NAME] ever live with someone while they worked for W. R. Grace or Zonolite? Yes No
IF NO, PLEASE SKIP TO QUESTION 18
Name
Name
Name
What is the [CHILD NAME] relationship to [INSERT NAME]?
Relationship
Relationship
Relationship
How long did [CHILD NAME] live with [INSERT NAME]?
Years
Years
Years
How many of the years that [CHILD NAME] lived with [INSERT NAME] did [INSERT NAME] work for W.R. Grace or Zonolite?
Years
Years
Years
How often did [INSERT NAME] wear his or her work clothes home? How often did you shower or change clothes before leaving work?
Never Sometimes Frequently
How often did [CHILD NAME] help with the laundry for [INSERT NAME]?
Never Sometimes Frequently
How often did [CHILD NAME] visit [INSERT NAME] while he/she was at work?
Never Sometimes Frequently
How often did [INSERT NAME] use the household car for work transportation?
Never Sometimes Frequently
POTENTIAL ENVIRONMENTAL EXPOSURES
To your knowledge, do any of the Lincoln County, Montana addresses you identified for [CHILD NAME] contain vermiculite insulation? Yes No
If YES, specify residence___________________________
Some products for the home, such as floor tiles, pipe insulation and siding can contain asbestos. Are you aware of any asbestos-containing products other than vermiculite that were present, or are still present, at any of the Lincoln County, Montana addresses you provided?
Yes No
If YES, specify asbestos-containing product and residence___________________________
Did [CHILD NAME] ever live at a residence where vermiculite from the mine/plant was used for gardening? Yes No
If YES, specify residence___________________________
Was vermiculite used around any of the addresses you identified for [CHILD NAME] for any purposes other than gardening? Yes No
If YES, specify purpose and residence___________________________
How often did [CHILD NAME] handle vermiculite insulation?
Never Sometimes Frequently
How often did [CHILD NAME] participate in recreational activities (hiking, hunting, etc.) along Rainy Creek Road?
Never Sometimes Frequently
How often did [CHILD NAME] play at the ball fields near the expansion plant?
Never Sometimes Frequently
How often did [CHILD NAME] play in or around the vermiculite piles?
Never Sometimes Frequently
If YES, where were these piles located? ___________________________
How often did [CHILD NAME] heat vermiculite ore to make it expand or pop?
Never Sometimes Frequently
How often did [CHILD NAME] participate in activities where you came into contact with vermiculite insulation, products, or ores not mentioned above?
Never Sometimes Frequently
If YES, please specify: ___________________________
TOBACCO USE
Has [CHILD NAME] ever smoked cigarettes? This means at least 400 cigarettes or 20 packs during his/her whole life.
Yes No
IF NO, PLEASE SKIP TO QUESTION 34.
Does [CHILD NAME] now smoke cigarettes (as of one month ago)? Yes No
How old was[CHILD NAME] when he/she first started smoking regularly? Age in years
If [CHILD NAME] has stopped smoking completely, how old was he/she when he/she stopped? Age in years
How many cigarettes does [CHILD NAME] now smoke per day? Cigarettes/day
On the average over the entire time [CHILD NAME] smoked, how many cigarettes did he/she smoke per day? Cigarettes/day
Has [CHILD NAME] ever smoked a pipe regularly? (Yes means more than 12 oz of tobacco in a lifetime.) Yes No
IF NO, PLEASE SKIP TO QUESTION 40.
How old was [CHILD NAME] when he/she started to smoke a pipe regularly? Age in years
If [CHILD NAME] has stopped smoking a pipe completely, how old was he/she when he/she stopped? Age in years
On the average over the entire time [CHILD NAME] smoked a pipe, how much tobacco did he/she smoke per week? oz/week
How much pipe tobacco is [CHILD NAME] smoking now? oz/week
Does or did [CHILD NAME] inhale pipe smoke? Yes No
Has [CHILD NAME] ever smoked cigars regularly? Yes No
(Yes means more than 1 cigar for a week for a year in a lifetime.)
IF NO, PLEASE SKIP TO QUESTION 46.
How old was [CHILD NAME] when he/she started to smoke cigars regularly? Age in years
If [CHILD NAME] has stopped smoking cigars completely, how old was he/she when he/she stopped? Age in years
On the average over the entire time [CHILD NAME] smoked cigars, how many cigars did he/she smoke per week? Cigars/week
How many cigars is [CHILD NAME] smoking per week now? Cigars/week
Do or did [CHILD NAME] inhale cigar smoke? Not at all/Slightly/Moderately/Deeply
Has [CHILD NAME] ever used or tried any smokeless tobacco products such as chewing tobacco or snuff? Yes No IF NO, PLEASE SKIP TO QUESTION 49.
While using smokeless tobacco, how many cans or pouches of tobacco does or did [CHILD NAME] use per week? ________________________________________________________________Containers/week
Do [CHILD NAME] currently use smokeless tobacco products every day, some days, or not at all?
____________________________________________________Every day/Some days/Not at all
Did any member of [CHILD NAME] family or household regularly smoke cigarettes inside the residence during the time that they lived together? Check yes for each person listed below.
IF YES, please indicate how many years you lived in the same household with them while they were smoking inside the residence.
Mother Yes No Years
Father Yes No Years
Spouse Yes No Years
Other Yes No Years
Other Yes No Years
Other Yes No Years
Are you currently living with someone who smokes inside the residence?
Yes No
Medical/Symptom History
Does [CHILD NAME] have a regular doctor or clinic that he/she goes to?
If YES, what is the name and address of the doctor or clinic?
Name
Address
Asbestos-Related Disease
Has his/her doctor ever told you that [CHILD NAME] has or treated him/her for asbestosis?
IF YES,
When was [CHILD NAME] first treated for asbestosis?
Is [CHILD NAME] currently receiving treatment for asbestosis?
Was [CHILD NAME] hospitalized for asbestosis?
Has his/her doctor ever told you that your child has or treated him/her for lung cancer?
IF YES,
When was [CHILD NAME] first treated for lung cancer?
Is [CHILD NAME] currently receiving treatment for lung cancer?
Was [CHILD NAME] hospitalized for lung cancer?
Has his/her doctor ever told you that your child has or treated him/her for mesothelioma?
IF YES,
When was [CHILD NAME] first treated for mesothelioma?
Is [CHILD NAME] currently receiving treatment for mesothelioma?
Was [CHILD NAME] hospitalized for mesothelioma?
Cough
Does [CHILD NAME] usually have a cough? Yes No
(Count a cough with first smoke or on fist going out-of-doors. Exclude clearing of the throat.)
IF NO, SKIP TO 56.
Does [CHILD NAME] usually cough as much as 4 to 6 times a day, 4 or more days out of the week? Yes No
Does [CHILD NAME] usually cough at all on getting up, or first thing in the morning?
Yes No
Does [CHILD NAME] usually cough at all during the rest of the day or night?
Yes No
IF YES TO ANY OF THE ABOVE, ANSWER THE FOLLOWING:
Does [CHILD NAME] usually cough like this on most days for 3 consecutive months or more during the year? Yes No
For how many years has he/she had this cough? Years
Phlegm
In the past year, has [CHILD NAME] ever coughed up phlegm (thick mucous) that was bloody? Yes No
IF NO, ask:
Has [CHILD NAME] ever coughed up phlegm that was bloody? Yes No
Does [CHILD NAME] usually bring up phlegm from your chest? Yes No
(Count phlegm with the first smoke or on first going out-of-doors. Exclude phlegm from the nose. Count swallowed phlegm.)
[IF NO, SKIP TO 63].
Does [CHILD NAME] usually bring up phlegm like this as much as twice a day, 4 or more days out of the week? Yes No
Does [CHILD NAME] usually bring up phlegm at all on getting up, or first thing in the morning? Yes No
Does [CHILD NAME] usually bring up phlegm at all during the rest of the day or at night?
Yes No
IF YES TO ANY OF 61-64, ANSWER THE FOLLOWING:
Does [CHILD NAME] bring up phlegm like this on most days for 3 consecutive months or more during the year? Yes No
For how many years has [CHILD NAME] had trouble with phlegm? Years
Episodes of cough and phlegm
Has [CHILD NAME] had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year?
*(For persons who usually have cough and/or phlegm.)
IF YES:
For how long has [CHILD NAME] had at least 1 such episode per year? Years
Other Medical/Symptom History
Has [CHILD NAME] ever had tuberculosis? Yes No
Has [CHILD NAME] ever been hospitalized for pneumonia or pleurisy? Yes No
Has [CHILD NAME] ever had congestive heart failure or fluid on the lungs? Yes No
Has [CHILD NAME] ever had any other chest illness? Yes No
Has [CHILD NAME] ever had a significant chest injury? Yes No
Has [CHILD NAME] ever had chest surgery (open heart or chest drainage tube)?
Yes No
Does [CHILD NAME] suffer from rheumatoid arthritis, scleroderma, or lupus?
Yes No
Has [CHILD NAME] ever had or have now have any type of cancer? Yes No
IF YES, Please specify the type of cancer:_____
IF YES, Please specify the year of diagnosis:_______
Has [CHILD NAME] ever had chest x-ray? Yes No
IF YES, What year did [CHILD NAME] have his/her most current chest x-ray? Year
IF YES, Where was this x-ray taken? Clinic and city:
Has [CHILD NAME] you ever been told by a doctor that he/she has a lung disease or condition? Yes No
IF YES, What kind(s) of lung condtion(s)?
IF YES, When were you told about it?
IF YES, Who told you about the problem? Dr.____
Has [CHILD NAME] become hoarse or developed difficulty swallowing in the last year?
Yes No
In the past year, has [CHILD NAME] had periods of chest pain related to breathing?
Yes No
Has [CHILD NAME] lost more than 15 pounds without dieting over the past 6 months?
Yes No
Is [CHILD NAME] troubled by shortness of breath when walking up a slight hill or when hurrying on level ground? Yes No
Does [CHILD NAME] have to walk slower than people his/her own age because of shortness of breath? Yes No
Does [CHILD NAME] have to stop for breath when walking at his/her own pace on level ground? ______________________________________________ Yes No
Does [CHILD NAME] have to stop for breath when walking about 100 yards (or after walking several minutes) on level ground? Yes No
Is [CHILD NAME] too short of breath to leave the house, or is he/she short of breath while dressing or undressing? Yes No
O
THER
INFORMATION
How concerned or worried are you that there is something in your neighborhood environment that may be harming your child’s health?
Not at all/A little/Very
We may ask to interview your child again in the future to check up on his/her health status. Keeping in mind that people move, we would like to get a little more information to help us locate your child in the future. Could we have the addresses of two people who live outside of your child’s household and who would always know how to find him/her? Yes No
IF YES:
Contact #1: Name/Phone Number/Address/Relationship
Contact #2: Name/Phone Number/Address/Relationship
Are there any comments you would like to add or any important information that you think we should know?:_____________________
Interviewer comments:________________
Thank you for participating.
Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0923-0039).
| File Type | application/msword |
| File Title | Appendix 6 |
| Author | ATSDR |
| Last Modified By | Ted Larson |
| File Modified | 2009-08-17 |
| File Created | 2009-03-18 |
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