1 Survey

Appendix A A.2.3.q–14

National Children’s Study

T3/ 24 Mo –TWO air badges QUESTIONNAIRE

DRAFT ONLY – NOT FOR DISTRIBUTION

• Use only a black, ball-point pen. Do not use a pencil or felt-tip pen.

• Put an X in the box next to your answer.

• If you make any changes, put a line through the incorrect answer  and put an X in the box next to the correct answer. Also, draw a circle around the correct answer .

1. When did you place the air badges in the room where you spend the most time?

MONTH	DAY		YEAR
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	0	0	2008 2009 2010 2011 2012 2013 2014 2015
	1	1
	2	2
	3	3
		4
		5
		6
		7
		8
		9

2. Approximately what time did you open the air badges?

HOUR	MIN	AM/PM
1 2 3 4 5 6 7 8 9 10 11 12	00 15 30 45	AM
		PM

3. In which room were the air badges placed?

₁ Common living area, such as a family room or a living room.

₂ Your bedroom/your child’s bedroom

₃ Kitchen

₆ Other, describe: _______ _

_

Question 4 appears at the top of the next column.

___________ _

4. Where did you hang the badges?

₁ Doorway or entrance to a room.

₂ Edge of a lamp shade

₃ Ceiling

₆ Other, describe: _______________ ______________________________

5. About how many feet above the floor did you place the badges?

|___|___| Feet

6. Were the air badges disturbed in any way during the period they were open in the room?

₀ No (SKIP TO QUESTION 5)

₁ Yes

6a. How were the air badges disturbed?

₁ They fell/were knocked down.

₆ Other, describe: _ _ ________________ __

7. About how many hours total during the week were the windows / doors open while the air badges were open?

₁ Less than one hour

₂ 1 – < 5 hours

₃ 5 – < 10 hours

₄ 10 –< 24 hours

₅ More than 24 hours

8. Which, if any, of the following products did you use in the room while the air badges were open (check all that apply)?

₁ Room fresheners / deodorizers

₂ Cleaning products

₃ Spray pesticides

₀ None of the above

9. Did anyone smoke in the room at any time while the air badges were open?

₀ No

₁ Yes

10. Were candles burning in the room at any time while the air badges were open?

₀ No

₁ Yes

11. Was a gas or propane stove or fireplace used at any time while the air badges were open?

₀ No

₁ Yes

12. What date did you close the air badges?

MONTH	DAY		YEAR
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	0	0	2008 2009 2010 2011 2012 2013 2014 2015
	1	1
	2	2
	3	3
		4
		5
		6
		7
		8
		9

13. Approximately what time did you close the air badges?

HOUR	MIN	AM/PM
1 2 3 4 5 6 7 8 9 10 11 12	00 15 30 45	AM
		PM

THANK YOU VERY MUCH FOR COMPLETING THIS QUESTIONNAIRE! ALL OF YOUR ANSWERS ARE VERY IMPORTANT.