1 Survey

Recruitment Strategy Substudy for the National Children's Study (NICHD)

A.2.3.s 1-T1 Environmental T1

Pregnancy Activities

OMB: 0925-0593

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Appendix A A.2.3.s–2

Version 12/18/07 Visit Type: T1 Mom

Target: Mother


Environmental Questions T1 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 bedroom, and air samples and dust wipe samples in the room where you spend the most time while you are 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 you spend the most time while you are awake, other than your kitchen?

COMMON LIVING AREA 1

BEDROOM 2

OTHER (SPECIFY:______________________ ) 6

REFUSED 7

DON’T KNOW 8


EQ005

Can you show me the room where you sleep 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 you sleep? By surface I mean what blanket or sheet do you 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?


GasHeat


YES

NO

RF

DK

a. GAS/FUEL HEAT?

1

2

7

8

b. GAS STOVE/OVEN?

1

2

7

8


EQ010

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 you spend the most time/bedroom and the room where you spend 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}”





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File Typeapplication/msword
File TitleHealth Behaviors (3
AuthorMegan Mitchell
Last Modified BySniffin_T
File Modified2008-01-25
File Created2008-01-24

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