SEED - Questionaire Packets

Form Approved

OMB NO. 0920-0741

Exp. Date: 6/30/2010

S tudy ID #: ______________

Date of Completion ________________

Study to Explore Early Development

Paternal Occupational Questionnaire/ Father’s Job History

This questionnaire asks about father’s work experience during the time around the birth of your child, so father should fill in if possible. We are interested in jobs that were paid, volunteer, or military service, which lasted one month or more for 10 or more hours per week. Please do not include stay-at-home parenting and education activities as a job, we ask about those separately. Please CIRCLE your response or fill in blanks where indicated.

Respondent’s relationship to the study child:

□ Biological Father            □ Step Father          □ Other: Specify ___________________

1A. Between 3 months before the pregnancy and the date of your child’s birth, did you have a job?

1 YES -- skip to question 2A 2 NO 9 DON’T KNOW

1B. If you were employed before this time, what was your usual job or job title?

______________________________________________

2A. Between 3 months before the pregnancy and the date of your child’s birth, were you enrolled as a regular (full-time) student? (i.e. not just taking 1 class)

1 YES 2 NO --skip to question 3A 9 DON’T KNOW

2B. During which months before or during your partner’s pregnancy were you a regular student? (CIRCLE ALL THAT APPLY)

Before your partner’s pregnancy:

3 months before 2 months before 1 month before

During your partner’s pregnancy (months):

1 2 3 4 5 6 7 8 9 Don’t Know

3A. What is the highest level of school you attend now (if currently full time student) or have completed (if no longer in school)?

0 LESS THAN HIGH SCHOOL

1 HIGH SCHOOL

2 VOCATIONAL SCHOOL

3 COLLEGE—UNDERGRAD

4 GRADUATE OR PROFESSIONAL SCHOOL

9 Don’t Know

3B. If you attended or are attending school beyond high school, what was/is your major field of study? ­­­­­­­­­­­_____________________________________________

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 10 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0741)

The remaining questions are about jobs during the time period around the pregnancy. Complete the remaining questions if you reported working a job or being in school during this time period. If you were not working a job and were not in school, you have finished this questionnaire. Thank you for your time!

______________________________________________________________________

IF YOU DID NOT WORK, BUT WERE IN SCHOOL, PLEASE SKIP TO Q11.

4. We would like to know more about the jobs that you held between 3 months before the pregnancy and the birth of your child that lasted one month or more at 10 or more hours/week. We are interested in types of jobs, so if you worked different jobs with the same employer, include those as separate jobs. But if you were self-employed or a contractor doing similar work for different companies, include that as one job.

Please list each job by your title, the name of the companies or organizations you worked for (or whether self-employed), and the city the company was located in, starting with the most recent during the pregnancy.

JOB TITLE EMPLOYER CITY/STATE

A. ______________________________________________________________________

B. ______________________________________________________________________

C. ______________________________________________________________________

D. ______________________________________________________________________

E. ______________________________________________________________________

Please answer questions 5-10 for each of the jobs you listed above (A-E). use A separate PAGE (provided) FOR EACH JOB.

AFTER YOU HAVE FINISHED THESE qUESTIONS FOR EACH JOB, GO TO Question 11.

Complete this page for job specified under 4a (Most Recent):

5A. Job title: ____________________________

6A. When did you start working at this job? (MONTH/YEAR)

7A. When did you stop working at this job? (MONTH/YEAR)

8A. How many hours per week did you work on this job during the pregnancy period?

_____ (HRS/WK)

9A. Please describe what type of business this was, or what the company made or did.

10A. Please describe your main duties or activities for this job, that is what you did each day and how you did it. Please be detailed.

________________

If you listed additional jobs on question 4, please complete the next job page. If you listed no other jobs, continue on to Question 11.

Complete this page for job specified under 4b:

5B. Job title (Fill in job title specified under 4B):

6B. When did you start working at this job? (MONTH/YEAR)

7B. When did you stop working at this job? (MONTH/YEAR)

8B. How many hours per week did you work on this job during the pregnancy period?

_____ (HRS/WK)

9B. Please describe what type of business this was, or what the company made or did?

10B. Please describe your main duties or activities for this job that is what you did each day and how you did it. Please be detailed.

________________

If you listed additional jobs on question 4, please complete the next job page. If you listed no other jobs, continue on to Question 11.

Complete this page for job specified under 4c:

5C. Job title (Fill in job title specified under 4C):

6C. When did you start working at this job? (MONTH/YEAR)

7C. When did you stop working at this job? (MONTH/YEAR)

8C. How many hours per week did you work on this job during the pregnancy period?

_____ (HRS/WK)

9C. Please describe what type of business this was, or what the company made or did?

10C. Please describe your main duties or activities for this job that is what you did each day and how you did it. Please be detailed.

________________

If you listed additional jobs on question 4, please complete the next job page. If you listed no other jobs, continue onto Question 11.

Complete this page for job specified under 4d:

5D. Job title (Fill in job title specified under 4C):

6D. When did you start working at this job? (MONTH/YEAR)

7D. When did you stop working at this job? (MONTH/YEAR)

8D. How many hours per week did you work on this job during the pregnancy period?

_____ (HRS/WK)

9D. Please describe what type of business this was, or what the company made or did?

10D. Please describe your main duties or activities for this job that is what you did each day and how you did it. Please be detailed.

________________

If you listed additional jobs on question 4, please complete the next job page. If you listed no other jobs, continue on to Question 11.

Complete this page for job specified under 4e:

5E. Job title (Fill in job title specified under 4C):

6E. When did you start working at this job? (MONTH/YEAR)

7E. When did you stop working at this job? (MONTH/YEAR)

8E. How many hours per week did you work on this job during the pregnancy period?

_____ (HRS/WK)

9E. Please describe what type of business this was, or what the company made or did?

10E. Please describe your main duties or activities for this job that is what you did each day and how you did it. Please be detailed.

________________

Please continue to Question 11.

11. At any of these jobs (or as a student), did you work with or around any substances or chemicals at least once per week? Please include substances such as solvents or degreasers, pesticides, heavy metals, or radioactive materials (includes X-rays).

1 YES 2 NO 9 DON’T KNOW

If you answered NO or DON’T KNOW to question 11, you have completed this questionnaire. Thank you! If you answered YES, please continue below.

We would like to know more about the chemicals or substances that you may have used. Some of the names may not look familiar to you, but answer as best you can.

12. Did you work with or around any of the following at least once per week at any job you described (or at school)?

If you answer ‘yes’ to any of the chemicals, please specify which months during the time period you were around this chemical. check all months in which exposure occurred OR MARK DON’T KNOW (DK).

1

2

9

Months before pregnancy

Months during pregnancy

YES

NO

DK

-3

-2

-1

1

2

3

4

5

6

7

8

9

Oil-based paints

Lacquers

Varnishes

Paint thinners

Paint strippers

Automotive fluids (SPECIFICS NOTED NEXT)

Freon

Antifreeze

Gasoline

Degreasers

Brake fluid

Toluene, xylene, styrene or benzene

Carbon disulfide

Carbon tetrachloride

Perchlorethylene (perc)

Trichloroethylene (TCE) or trichlorethane (TCA)

Vinyl chloride

1

2

9

Months before pregnancy

Months during pregnancy

YES

NO

DK

-3

-2

-1

1

2

3

4

5

6

7

8

9

Glycol ethers

Alcohols, such as methanol or ethanol

Adhesives or glues, like rubber cement

Any other solvents or degreasers? (PLEASE SPECIFY) 1. 2.

Phthalates

Cutting oils

Cooling or lubricating oils

PCBs

Metals (SPECIFICS FOLLOW)

Lead

Nickel

Chromium

Mercury

Manganese

Metal dust or fumes

Others? PLEASE SPECIFY:

Anesthetic gases

Ethylene oxide

Pesticides or herbicides, e.g. bug or weed killers (SPECIFY & NAME BELOW IF KNOWN)

Herbicides

Fungicides

Insecticides

Rat poison

X-ray or radioactive materials

Diesel fumes

Pharmaceuticals or drugs SPECIFY:

Any other? (please specify) 1.

2.

12B. Please describe the activities you did around these substances and which job you were working at when you used them. Include how many hours per week you were around them.

12C. Did you work mostly indoors, outdoors, or both where you used these chemicals?

1 INDOORS

2 OUTDOORS

3 BOTH

9 DON’T KNOW

12D. When you were around these, did you usually use any protective gear or equipment such as gloves, masks, respirators or fume hoods?

1 YES 2 NO

12E. IF YES: Which did you use? (CIRCLE ALL THAT APPLY)

1 GLOVES OR PROTECTIVE CLOTHING

2 GOGGLES

3 MASK

4 RESPIRATOR

5 FUME HOOD OR LOCAL VENTILATION

6 OTHER (Specify):______________________

9 DON’T KNOW

Thank you! You have completed this questionnaire.

Version 9-07 SNC Page 1 of 10