1 Survey

Appendix A A.2.3.q–3

National Children’s Study

T3/24 Mo – one air badge collection instructions

DRAFT ONLY – NOT FOR DISTRIBUTION

READ STEPS 1 – 12 BEFORE SETTING UP THE AIR BADGE.
INSTRUCTIONS FOR SET-UP OF AIR BADGE
1) Remove contents of the air badge collection kit. 2) Choose the room in your home where you spend the most time while you are awake (other than a kitchen). This could be a living room, family room, bedroom, etc.	Photo 1: Contents of air badge collection kit with each item labeled by name.
3) Choose a location to hang the air badge where they will not be disturbed. The air badge should remain in this location for one week. Ideally, the air badge should be at least 4 ft. from the floor and 1 ft. from a wall, like the edge of a lampshade. If your room does not have any lamps, you may choose any other location such as a ceiling or doorway. Do not attach the anchor to a wall. 4) Remove the paper backing from the stick on anchor. In the spot chosen in step 2, stick the anchor in place.	Photo 2: Lampshade with removable anchor attached.
	Photo 3: Doorway with removable anchor.
	Instructions continued on page 2

INSTRUCTIONS FOR SET-UP OF AIR BADGE
5) Wash your hands with soap and water. Rinse well and dry thoroughly. Put on disposable gloves. 6) Remove the contents of the air badge collection kit, take out the “T3/24 Mo – Air Badge Questionnaire” and write down today’s date (question 1). 7) Unpack each of the passive air badge and the air badge holder and attached hanging wire.	Photo 4: Opening air sample collection containers.
	Photo 5: Air badge clipped to the plastic air badge holder.
8) Clip each air badge onto the air badge holder in one of the spots provided. 9) Remove the attached cap from each air badge and then write down the start time on the “T3/24 Mo – One Air Badge Questionnaire” (question 2).	Photo 6: The air badge clipped to the air badge holder and hand removing cap from the air badge
	Instructions continued page 3

INSTRUCTIONS FOR SET-UP OF AIR BADGE
10) Hang the air badge holder to the ceiling anchor using the hanging wire.	Photo 7: Badge and badge holder hanging from the ceiling anchor.
11) Place the contents of the air badge collection kit back in the bag. Throw away the disposable gloves. 12) Leave the air badge open and hanging for at least 7 days, but not longer than 8 days.	Photo 8: Contents of the air badge collection kit being placed back in the bag.
Thank you for setting up the air badge. After 7 or 8 days, please take down and ship the air badge according to the instructions below.

READ STEPS 1 – 11 BEFORE TAKING DOWN THE AIR BADGE.
INSTRUCTIONS FOR TAKING DOWN AND SHIPPING THE AIR BADGE
1) Wash your hands with soap and water. Rinse well. Put on a clean set of disposable gloves. 2) Remove the contents of the air badge collection kit, take out the “T3/24 Mo – One Air Badge Questionnaire” and write down today’s date (question 11). 3) Take down the air badge holder and air badge.	Photo 9: Gloved hands taking down the air badge holder from the ceiling.
4) Replace the cap on each air badge and make sure it is completely sealed. Write down the stop time on the “T3/24 Mo – One Air Badge Questionnaire” (question 12).	Photo 10: Photo showing gloved hands replacing the cap on the air badge.
	Photo 11: Photo showing person removing anchor from the edge of a lampshade.
	Instructions continued page 2

INSTRUCTIONS FOR TAKING DOWN AND SHIPPING THE AIR BADGE
5) Unclip each air badge from the air badge holder and place each in its own pouch. Seal each pouch shut. Place the air badge into the larger Ziploc bag and seal shut. 6) Complete the “T3/24 Mo – One Air Badge Questionnaire.”	Photo 12: Photo showing gloved hands sealing the air badge in the pouches and the larger Ziploc bag with “T3/24 Mo – One Air Badge Questionnaire” in the background.
7) Place the following items in the return mailing envelope: - Ziploc bag containing the air badge - Completed “T3/24 Mo – One Air Badge Questionnaire”. 8) Place the mailing envelope in the US mail within 12 hours of placing the cap on the air badge.	Photo 13: Photo showing a Ziploc bag containing air badge, and completed “T3/24 Mo – One Air Badge Questionnaire” being placed into the pre-addressed mailing envelope.
Thank you for sending in your air badge. Your continued participation in this study is greatly appreciated.

• 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 badge 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 badge?

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 was the air badge 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 badge?

₁ Cased opening

₂ Edge of a lamp shade

₃ Ceiling

₆ Other, describe: _______________ ______________________________

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

|___|___| Feet

6. Was the air badge disturbed in any way during the period it was open in the room?

₀ No (SKIP TO QUESTION 5)

₁ Yes

6a. How Was the air badge disturbed?

₁ It fell/Was knocked down.

₆ Other, describe: _ _ ________________ __

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

₀ No

₁ Yes

10. Were candles burning in the room at any time while the air badge was open?

₀ No

₁ Yes

11. What date did you close the air badge?

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

12. Approximately what time did you close the air badge?

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.

READ STEPS 1 – 12 BEFORE SETTING UP THE AIR BADGES.
INSTRUCTIONS FOR SET-UP OF AIR BADGES
1) Remove contents of the air badges collection kit. 2) Choose the room in your home where you spend the most time while you are awake (other than a kitchen). This could be a living room, family room, bedroom, etc.	Photo 1: Contents of air badges collection kit with each item labeled by name.
3) Choose a location to hang the air badges where they will not be disturbed. The air badges should remain in this location for one week. Ideally, the air badges should be at least 4 ft. from the floor and 1 ft. from a wall, like the edge of lampshade. If your room does not have any lamps, you may choose any other location such as a ceiling or doorway. Do not attach the anchor to a wall. 4) Remove the paper backing from the stick on anchor. In the spot chosen in step 2, stick the anchor in place.	Photo 2: Lampshade with removable anchor attached.
	Photo 3: Doorway with removable anchor.
	Instructions continued on page 2

INSTRUCTIONS FOR SET-UP OF AIR BADGES
5) Wash your hands with soap and water. Rinse well and dry thoroughly. Put on disposable gloves. 6) Remove the contents of the air badges collection kit, take out the “T3/24 Mo – Two Air Badges Questionnaire” and write down today’s date (question 1). 7) Unpack each of the passive air badges and the air badge holder and attached hanging wire.	Photo 4: Opening air sample collection containers.
	Photo 5: Air badges clipped to the plastic air badge holder.
8) Clip each air badge onto the air badge holder in one of the two spots provided. 9) Remove the attached cap from each air badge and then write down the start time on the “T3/24 Mo – Two Air Badges with Questionnaire” (question 2).	Photo 6: The two air badges clipped to the air badge holder and hand removing cap from one of the air badges (the other is already uncapped).
	Instructions continued page 3

INSTRUCTIONS FOR SET-UP OF AIR BADGES
10) Hang the air badge holder to the ceiling anchor using the hanging wire.	Photo 7: Badges and badge holder hanging from the ceiling anchor.
11) Place the contents of the air badges collection kit back in the bag. Throw away the disposable gloves. 12) Leave the air badges open and hanging for at least 7 days, but not longer than 8 days.	Photo 8: Contents of the air badges collection kit being placed back in the bag.
Thank you for setting up the air badges. After 7 or 8 days, please take down and ship the air badges according to the instructions below.

READ STEPS 1 – 11 BEFORE TAKING DOWN THE AIR BADGES.
INSTRUCTIONS FOR TAKING DOWN AND SHIPPING THE AIR BADGES
1) Wash your hands with soap and water. Rinse well. Put on a clean set of disposable gloves. 2) Remove the contents of the air badges collection kit, take out the “T3/24 Mo – Two Air Badges Questionnaire” and write down today’s date (question 12). 3) Take down the air badge holder and air badges.	Photo 9: Gloved hands taking down the air badge holder from the ceiling
4) Replace the cap on each air badge and make sure it is completely sealed. Write down the stop time on the “T3/24 Mo – Two Air Badges Questionnaire” (question 13).	Photo 10: Photo showing gloved hands replacing the cap on the air badges.
	Photo 11: Photo showing person removing anchor from the edge of a lampshade.
	Instructions continued page 2

INSTRUCTIONS FOR TAKING DOWN AND SHIPPING THE AIR BADGES
5) Unclip each air badge from the air badge holder and place each in its own pouch. Seal each pouch shut. Place the two air badges into the larger Ziploc bag and seal shut. 6) Complete the “T3/24 Mo – Two Air Badges Questionnaire”.	Photo 12: Photo showing gloved hands sealing up the air badges in the pouches and the larger Ziploc bag with “T3/24 Mo – Two Air Badges Questionnaire” in the background.
7) Place the following items in the return mailing envelope: - Ziploc bag containing the air badges - Completed “T3/24 Mo – Two Air Badges Questionnaire” 8) Place the mailing envelope in the US mail within 12 hours of placing the cap on the air badge.	Photo 13: Photo showing a Ziploc bag containing air badges, and completed T3/24 Mo – Air Badges with NO2 Questionnaire being placed into the pre-addressed mailing envelope.
Thank you for sending in your air badges. Your continued participation in this study is greatly appreciated.

• 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.

DRAFT ONLY – NOT FOR DISTRIBUTION

Call 800-XXX-XXX if you have any questions about collection of this sample.