1 Survey

Appendix A A.2.3.s–5

Version 12/18/07 Visit Type: 6Mo, 12Mo Target: Mother

Environmental Questions 6Mo 12Mo Visit

EQ001	I will be conducting the environmental sample collection in your home today. I would like to collect a vacuum dust sample in your child’s bedroom, and air samples and dust wipe samples in the room where your child spends the most time while awake. I may collect a water sample from your kitchen as well. We need to collect the air samples over a one week period. So, I will set up an air sampling station today and start air sample collection. In about a week, someone will come back to pick up the air sample equipment. We will work with you to schedule a time for the pick up visit. First, I have a few questions to help me determine where to collect these samples.
EQ002	Is the tap water in your home from a private well? YES 1 NO 2 REFUSED 7 DON’T KNOW 8
EQ004	Can you show me the room where your child spends the most time while awake, other than the kitchen? COMMON LIVING AREA 1 BEDROOM 2 OTHER (SPECIFY:______________________ ) 6 REFUSED 7 DON’T KNOW 8
EQ005	Can you show me the room where the child sleeps the majority of the time? COMMON LIVING AREA 1 BEDROOM 2 OTHER (SPECIFY:______________________ ) 6 REFUSED 7 DON’T KNOW 8

EQ006

Can you show me the surface of the bed on which the child sleeps? By surface I mean what blanket or sheet does the child sleep directly on top of? Sheet 1 Mattress pad or cover 2 Blanket/sleeping bag/comforter 3 Bare mattress 4 Bare floor 5 OTHER (SPECIFY:______________________) 6 REFUSED 7 DON’T KNOW 8

EQ007	Do you have any non-electric appliances in your home, such as a stove or oven, a furnace, water heater, dryer, or a gas, oil, or kerosene space heater? YES 1 NO 2 (EQ010) REFUSED 7 (EQ009) DON’T KNOW 8 (EQ009)
EQ008	Can you show me these appliances? . YES 1 (EQ010) NO 2 (EQ010)

EQ009

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

	YES	NO	RF	DK
a. GAS/FUEL HEAT?	1	2	7	8
b. GAS STOVE/OVEN?	1	2	7	8

EQ010

Do you have any electric air cleaners, photocopiers, or Laserjet printers in the home?

YES 1

NO 2 (EQ013)

REFUSED 7 (EQ012)

DON’T KNOW 8 (EQ012)

EQ011

Can you show me these appliances?

YES 1 (EQ013)

NO 2 (EQ013)

EQ012

If you have a printer or air cleaning device, can you show it to me?

	YES	NO	RF	DK	NA
a. LASERJET PRINTER OR PHOTOCOPIER?	1	2	7	8	9
b. OZONE GENERATING AIR CLEANER?	1	2	7	8	9

EQ013

Thank you so much. In order to shorten the length of our visit today, it would be helpful if I could collect the environmental samples while you are being interviewed. I will need to go into your {kitchen, bedroom, and the room where the child spends the most time/bedroom and the room where the child spends the most time}. Would it be okay for me to collect these samples during your interview? YES 1 NO 2 DISPLAY INSTRUCTION: IF TARGET = DISINFECTION BYPRODUCTS OR IF EQ002 IN "1", "7", "8", DISPLAY “{bedroom, kitchen, and the room where you spend the most time}” OTHERWISE, DISPLAY “bedroom and the room where you spend the most time while you are awake}”