1 Survey

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? WaterSource 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? RmMostTimeWhileAwake 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? RoomSleep 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? SurfaceWhereSleep 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? No2SourceInHome YES 1 NO 2 (EQ010) REFUSED 7 (EQ009) DON’T KNOW 8 (EQ009)

EQ008

Can you show me these appliances?

Show No2Source

YES 1 (EQ010)

NO 2 (EQ010)

EQ009

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

GasStove

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?

EnviroDuringInterview

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}”

DRAFT ONLY – NOT FOR DISTRIBUTION