1 Survey

Appendix A A.2.3.o–3

N ATIONAL CHILDREN’S STUDY

T3 House dust plate 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. Please record the date you set out the dust plate:

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. In which room did you leave the dust plate?

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

₂ Your bedroom

₃ Kitchen

₆ Other, specify: ___________________

_ _

3. Where in the room did you leave the dust plate?

₁ On a bookshelf

₂ On top of an entertainment center

₃ On a table (end table, coffee table, etc.)

₆ Other, specify: ___________________

_ _

4. About how many feet above the floor did you place the dust plate?

|___|___|Feet

5a. Did you run into any problems when collecting the dust plate?

₀ No (go to question #6)

₁ Yes

5b. What problems did you have when collecting the dust plate:

₁ Plate fell

₆ Other, specify: _ _

_

If the dust plate was somehow destroyed, please call 1-800-XXX-XXXX.

6. When was the dust plate taken down and prepared for shipment?

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

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