1 Survey

Appendix A A.2.3.r–3

N ational Children’s study

24 mo – pesticide wipe instructions

DRAFT ONLY – NOT FOR DISTRIBUTION

READ STEPS 1 – 11 BEFORE STARTING.
1. Choose the room in your home where your child spends most the most time while he or she is awake. This could be a living room, family room, bedroom, etc. 2. Bring to the room chosen in step 1: the pesticide wipe collection kit (see photo 1). the ballpoint pen provided. the “24 Mo – Pesticide Wipe Collection Instructions.” 3. Wash your hands with soap and water. Rinse well and dry. Put on the enclosed disposable gloves.	Photo 1: Pesticide wipe collection kit
4. Remove the template from the collection kit. Place it in an open floor area in the room. Tape down the outer edges with the provided tape (see photo 2).	Photo 2: Template taped to the floor
5. Tear open one of the wipe packages. Remove the wipe and unfold it completely. With your fingers together, grasp the wipe between your thumb and palm. Press the wipe at the top corner of the template, firmly, but not excessively, and continue to wipe side to side with an overlapping “s”-like motion until you have wiped the entire interior of the template.	Photo 3: Hand pressing wipe in the top, right-hand corner of the template, with arrows demonstrating the side to side “s” like motion.
6. Fold the wipe in half with the dusty side facing inward. Again, place the wipe in the top corner of the template and repeat wiping the area with an overlapping “s”-like motion, this time working from top to bottom.	Photo 4: Hand pressing wipe in the top, right-hand corner of the template, with arrows demonstrating the top to bottom “s”-like motion.
7. Fold the wipe in half again with the dusty side on the inside. Place it in a 2-oz amber glass jar labeled “24 Mo –Pesticide Wipe #1.” 8. Remove the template from the floor and tape down to a different floor area in the same room. Repeat steps 5 & 6 for this wipe. Fold the whip in half with the dusty side facing inward and place it in the 2‑oz amber glass jar labeled “24 Mo – Pesticide Wipe #2.” 10. Complete the “24 Mo – Pesticide Wipe Collection Instructions.”	Photo 5: Two labeled, 2‑oz amber glass jar, tubes containing pesticide wipes, and “24 Mo – Pesticide Wipe Questionnaire.”
11. Place the each 2-oz amber glass jar in a bubble bag. Then, place the bubble-wrapped jars in a Ziploc bag. Finally place the bagged jars and the “24 Mo – Pesticide Wipe Collection Instructions” in the mailing envelope which was included in the pesticide wipe collection kit. Mail the package within 12 hours.	Photo 5: Two bubble-wrapped, 2‑oz amber glass jars and “24 Mo – Pesticide Wipe Questionnaire” being placed into the pre-addressed mailing envelope
Call 800-XXX-XXX if you have any questions about collection of this wipe.

• 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 collected the wipes:

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 were the two wipes taken:

₁ Family or living room

₂ Your child’s bedroom

₃ Kitchen

₆ Other, specify: ___________________

3. What type of surface did you wipe when you collected Pesticide Wipe 1?

₁ Tile or Linoleum

₂ Wood floor

₃ Room-sized rug or wall-to-wall carpet

₄ Small area rug

₆ Other, specify: ___________________

4. What type of surface did you wipe when you collected Pesticide Wipe 2?

₁ Tile or Linoleum

₂ Wood floor

₃ Room-sized rug or wall-to-wall carpet

₄ Small area rug

₆ Other, specify: ___________________

5. Did you run into any problems when taking the pesticide wipes?

₀ No (SKIP TO QUESTION 7)

₁ Yes

5a. Which wipe did you run into problems with?

₁ Pesticide Wipe 1

₂ Pesticide Wipe 2

₃ Both Pesticide Wipes

5b. What problems did you have when collecting the wipe(s)?

₁ Wipe ripped, Wipe 1

₂ Wipe ripped, Wipe 2

₃ Could not wipe the entire area, Wipe 1

₄ Could not wipe the entire area, Wipe 2

₅ Wiped outside the area, Wipe 1

₆ Wiped outside the area, Wipe 2

₉₆ Other, specify: __________________

Thank you very much for completing this questionnaire! All of your answers are very important.