Form 1 Biological Sample Collection Questionnaire (Randomly Sel

Home Visit CAPI Instrument 1/7/10

Biological Sample Collection Questionnaire

Agricultural Health Study

Location of Residence (County, State): ___________________

Date: _____/______/______

MM DD YYYY

OMB #: 0925-0406

Expiration date: 10/31/2011

Public reporting for this collection of information is estimated to average 1.5 hours 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 (0925-0406). Do not return the completed form to this address.

[Display subject ID and Participant information on CAPI “face sheet”]

Screening questions to ask prior to consent:

1. Is your name ^DSP.Respondent_Fullname and is your date of birth ^STN.Respondent_Birthdate?

Yes _____ No _____ (if no, answer the following question)

Does another person with a similar name but a different date of birth live here?

Yes _____ No _____ (if no, answer the following question)

Is it possible that the numbers in the date of birth, ^STN.Respondent_Birthdate, have been transposed, misread, or are reversed?

Yes _____ No _____ (if yes, answer the following question)

What is your correct date of birth? ______/_______/________

MM DD YYYY

2. Do you have a blood clotting disorder such as hemophilia?

Yes _____ No _____ (This question will also be asked on the screening call. If yes, the individual will be ineligible.)

3. Other than non-melanoma skin cancer, have you been diagnosed by a doctor with any type of cancer in the last three years? (This will also be asked on the screening call. If yes, the individual will be ineligible.) Yes _____ No _____

1. If yes, list each cancer and date of diagnosis (add additional rows as needed):

1^st cancer _____________________________date of diagnosis _____/______/______

MM DD YYYY

2^nd cancer (if applicable)_________________ date of diagnosis _____/______/_____

MM DD YYYY

4. Have you ever had a digital rectal examination of the prostate? Would you say never, once, or more than once?

No _____ Yes _____ Yes, more than once _____ Don’t know _____

5. Have you ever had a blood test for prostate cancer, for example PSA? Would you say never, once, or more than once?

No _____ Yes _____ Yes, more than once _____ Don’t know _____

6. Have you ever has a colonoscopy or sigmoidoscopy to examine the colon and rectum? Would you say never, once, or more than once?

No _____ Yes _____ Yes, more than once _____ Don’t know _____

[Obtain consent, and proceed with questionnaire]

1. How tall are you? ____________________feet / inches

2. How much do you weigh now? ____________________ pounds

3. In the last 7 days, have you used aspirin or aspirin-containing products, such as Bayer, Bufferin, or Anacin? (Please do not include aspirin-free products such as Tylenol and Panadol.)

Yes _____ No _____ (if yes, answer the following questions)

1. Product name: _______________

2. Product strength: Adult strength (usually 325mg) _____ Baby strength (usually 81mg) _____ Some other strength _____ Don’t know the strength _____

3. How many pills of aspirin or aspirin-containing products have you taken in the last 7 days? ______

4. When did you last take aspirin or aspirin-containing products? ______/_______/________

MM DD YYYY

4. In the last 7 days, have you used ibuprofen-containing products, such as Advil, Nuprin, or Motrin? Yes _____ No _____ (if yes, answer the following questions)

   1. Product name: _______________

   2. How many pills of ibuprofen-containing products have you taken in the last 7 days? ____

   3. When did you last take ibuprofen-containing products? ______/_______/________

MM DD YYYY

5. Are you regularly taking any blood thinning medications (e.g. Heparin, Coumadin)?

Yes _____ No _____

1. If yes, please list the blood thinning medication(s) that you regularly take: _________________________________________________________________________

6. Do you regularly take any prescribed medicines? Yes _____ No _____

   1. If yes, list each prescription medication taken: __________________________________

___________________________________________________________________________

7. Have you ever been diagnosed with any of the following conditions?

Heart disease: Yes _____ No _____

Diabetes: Yes _____ No _____

Autoimmune conditions (e.g., multiple sclerosis, sarcoidosis, lupus, or Sjogren’s disease): Yes _____ No _____

Arthritis: Yes _____ No _____

High blood pressure or hypertension: Yes _____ No _____

8. Have you had any of the following conditions in the last 30 days?

1. Cold or flu: Yes _____ No _____ (if yes, answer below)

When did symptoms begin? _______________

When did symptoms resolve? _______________

2. Bronchitis or pneumonia: Yes _____ No _____ (if yes, answer below)

When did symptoms begin? _______________

When did symptoms resolve? _______________

3. Sinusitis or sinus problems: Yes _____ No _____ (if yes, answer below)

When did symptoms begin? _______________

When did symptoms resolve? _______________

4. Any other type of infection: Yes _____ No _____ (if yes, answer below)

List type(s)_______________________________________________________

When did symptoms begin? _______________

When did symptoms resolve? _____________

9. During the last 12 months, have you had any medical or dental x-rays or any other radiologic procedures?

Yes _____ No _____

1. If yes, list each:

Type of procedure: _______________

Date of procedure: _______/_______/________

MM DD YYYY

10. How many servings of alcoholic beverages did you drink in the last seven days? A serving of an alcoholic beverage is defined as 12 fluid ounces of beer, 5 fluid ounces of wine, and 1.5 fluid ounces of hard liquor. Number of servings: __________

11. How many servings of alcoholic beverages did you drink in the last 24 hours? A serving of an alcoholic beverage is defined as 12 fluid ounces of beer, 5 fluid ounces of wine, and 1.5 fluid ounces of hard liquor. Number of servings: __________

12. How often do you currently smoke or use the following tobacco products?

Product	Every day	Some days	Not at all
Cigarettes
Pipe
Cigars
Cigarillos
Chewing tobacco
Snuff
Other (specify): __________

Other agricultural exposures section

Now we would like to ask you a few questions about your activities at work and on your farm.

13. In the last 12 months, have you personally performed farm work or farming activities?

Yes _____ No _____ (if no, skip to welding question)

14. Excluding gardens for personal use, what crops, including fruits and vegetables, were raised on your farm in the last 12 months?

None

Apples

Alfalfa

Barley

Bermuda grass

Blueberries

Cabbage

Christmas trees

Corn field

Corn pop

Corn seed

Corn sweet

Cotton

Cucumbers

Grapes

Hay or forage

Melons

Oats

Peaches

Peanuts

Peppers

Potatoes

Rye

Snap beans

Sorghum

Soybeans

Strawberries

Sweet potatoes

Tomatoes

Tobacco

Wheat

Nursery crops

Pumpkins

Other: __________

15. In the last 12 months, what type and number of poultry or livestock were raised on your farm?

Type	Yes/No	Number
None
Beef cattle
Dairy cattle
Hog/swine
Poultry
Poultry for eggs
Sheep or goats
Horses
Other

16. If yes to raising poultry or poultry for eggs, have you spent time in a poultry confinement area within the last month?

Yes___ No____

17. If yes to swine, have you spent time in swine confinement area within the last month?

Yes___ No___

18. In the last month, how many times have you performed the following activities?

Grind animal feed	Not at all 1-3 times 4-20 times >20 times
Milk cows	Not at all 1-3 times 4-20 times >20 times
Clean grain bins	Not at all 1-3 times 4-20 times >20 times
Work with or around moldy hay or straw	Not at all 1-3 times 4-20 times >20 times

19. In the last 7 days, have you done any welding? Yes _____ No _____

20. In the last 7 days, have you done any painting? Yes _____ No _____

21. In the last 7 days, have you repaired engines? Yes _____ No _____

Non-farm occupation information

22. Do you currently have a job other than working on a farm?

Yes _____ No _____ (If yes, please answer the following questions)

1. What is your current job other than farming? ______________________________

2. What type of business is this job in? ______________________________

3. How long have you had this job? _______________ months / years

4. Is this job year round or seasonal?

Year round _____ Seasonal _____

Occupational Pesticide Use Module

We would now like to ask about your use of pesticides in the last 12 months. This includes the use of herbicides, insecticides, fungicides, fumigants, or other chemicals used to kill plants, insects, fungi, molds, or rodents. Please do not include the use of antibiotics, sanitizers, antimicrobial soaps or fertilizers.

1. In the last 12 months, have you personally mixed, loaded, handled or applied these chemicals for use on crops, animals, or any other purpose NOT including home and garden use? We will ask you separately about the use of pesticides in your home and garden.

Yes _____ No _____ (If no, then stop here. If yes, please answer the following questions in a separate module for each product used.)

2. Which products have you used in the last 12 months? Please give the product trade name, if possible:

_____________________________________________________________________________________

If label is available, active ingredient and EPA Registration #: ____________________

3. In the last 12 months, on how many days did you mix, load or apply [insert pesticide name]?

Total number of days: __________

Don’t know

4. We would like to ask you about the dates of the three most recent uses of [insert pesticide name] within the last 12 months and the amount of time that you spent mixing, loading or applying [insert pesticide name] on each date.

	Date (start with most recent use)	Time spent (hours)
1
2
3

5. In the last 12 months, did you personally mix or load [insert pesticide name]?

Yes _____ No _____ (If yes, answer below)

1. Was the pesticide product that you mixed/loaded a:

Liquid

Powder

Granule

Dissolvable packet

Other: specify ____________________

2. What type of personal protective equipment did you wear when mixing/loading [insert pesticide name]? Please select all that apply:

Gloves, specify type: chemical resistant (like nitrile)

rubber or plastic waterproof gloves

thin disposable glove (like latex)

fabric or leather
other gloves: __________

Goggles

Face shield

Disposable coveralls, like Tyvek

Chemical-resistant jacket and pants

Chemical-resistant apron

Rubber boots

Respirator, specify type: __________________

Dust mask

Long-sleeved shirt

Other: specify________________

None

6. In the last 12 months, did you personally apply [insert pesticide name]?

Yes _____ No _____ (If yes, answer below)

1. Was [insert pesticide name] applied to:

Crop(s), specify: _______________

Animals or animal confinement areas

Other, specify: _______________

2. Was [insert pesticide name] applied as a liquid, powder, granule or something else?

Liquid

Powder

Granule

Something else: specify _______________

3. What application method(s) was used?

Broadcast or boom spray

Hand spray

Air blast

Other: specify_________________

4. What type of personal protective equipment did you wear when applying [insert pesticide name]? Please select all that apply:

Gloves, specify type: chemical resistant (like nitrile)

rubber or plastic waterproof gloves

thin disposable glove (like latex)

fabric or leather
other gloves: __________

Goggles

Face shield

Disposable coveralls, like Tyvek

Chemical-resistant jacket and pants

Chemical-resistant apron

Rubber boots

Respirator, specify type: __________________

Dust mask

Long-sleeved shirt

Other: specify________________

None

Home and Garden Pesticide Use Questions

We would now like to ask about your use of pesticides in your home and garden in the last 12 months. This includes the use of herbicides, insecticides, fungicides, fumigants, or other chemicals used to kill plants, insects, fungi, molds, or rodents. Please do not include the use of antibiotics, sanitizers, antimicrobial soaps or fertilizers.

1. In the last 12 months, have you personally used pesticides in your home and garden?

Yes _____ No _____ (If no, then stop here. If yes, please answer the following question.)

2. Which products have you used in your home and garden in the last 12 months? Please give the product trade name, if possible: _________________________________________________________________

If label is available, active ingredient and EPA Registration #: ____________________

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