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Morbidity Study of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune

attachment C survey 11_10 clean

OMB: 0923-0042

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Survey ID# _ _ _ _ _ _ _ _ OMB Number: 0923-xxxx

Expiration Date xx/xx/20xx




Marine Corps Health Survey




Instructions

  • Please use a black or blue pen to complete this form. Do not use a felt-tip pen or a pencil.

  • Mark X to indicate your answer.

  • If you want to change your answer, mark an X on the wrong answer and put an X in the box next to the correct answer.

  • Your answers are important. Please print clearly, using uppercase, block letters (for example, “WEDNESDAY”).



1. Are you completing this survey for yourself?

Yes GO TO RESIDENTIAL HISTORY ON PAGE XX

No



2. Is the person to whom this survey is addressed unable to complete the survey or is he/she deceased?

Unable

Deceased



If you are filling out this survey on behalf of someone else, please provide your name and other information requested below.


Your Name:

First: __________________ Middle: ______________ Last: __________________

Suffix (Jr., Sr., etc.): _____





Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0923-xxxx).



3. What is your relationship to the person for whom you are completing this survey?

Shape1 Spouse


Were you married to the participant while he/she was living or working at Camp Lejeune or Camp Pendleton?

Yes

No

Sibling

Parent

Child

Cousin

Other-specify: _____________________________


IMPORTANT: Please answer all questions in this survey as they relate to the participant. In each question, the word “you” will refer to the participant, not yourself.








Residential History


  1. Were you active duty at Camp Lejeune or Camp Pendleton?

Yes

No GO TO QUESTION 10



























Please use the table below to tell us about the time you lived at Camp Lejeune or Camp Pendleton. After completing the table, go to Medical History section on page XX.



5. Where were you stationed?

(Please mark one.)


6. What unit were you assigned to?

7. Where on base did you reside?

(location of barracks/family housing area)

8. When did you start living there? (month and year)

9. When did you stop living there? (month and year)

Lejeune

Pendleton



________________

______________

______________

/

/

Lejeune

Pendleton



________________

______________

______________

/

/

Lejeune

Pendleton



________________

______________

______________

/

/

Lejeune

Pendleton



________________

______________

______________

/

/

Lejeune

Pendleton



________________

______________

______________

/

/


GO TO MEDICAL HISTORY SECTION ON PAGE XX







  1. Were you living with someone while they were active duty at Camp Lejeune or Camp Pendleton?

Yes Please give us the full name of the active duty member.

_______________________________________________________

No GO TO MEDICAL HISTORY SECTION ON PAGE XX
















Use the table below to tell us about the time you lived at Camp Lejeune or Camp Pendleton.



  1. Where were you living?

(Please mark one.)

  1. What was the address?

(street number, street name or housing area)

13a. Start Month

13b. Start

Year

14a. End Month

14b. End

Year

Lejeune

Pendleton

________________________________________

m m

y y y y

m m

y y y y

Lejeune

Pendleton

________________________________________

m m

y y y y

m m

y y y y

Lejeune

Pendleton

________________________________________

m m

y y y y

m m

y y y y

Lejeune

Pendleton

________________________________________

m m

y y y y

m m

y y y y




Medical History


We are interested in finding out about any diseases, medical conditions, and illnesses you may have had since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton.



  1. What is the name, address, and phone number of your current primary care doctor or health care provider?

Doctor Name: ____________________________________________

Address: _______________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________


16. Between the time you were first stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, have you been told by a doctor or other health care provider that you had cancer or a malignancy of any kind?

Yes

No GO TO QUESTION 30 ON PAGE









17. Thinking of the first diagnosed cancer, what kind of cancer was it? (Mark only one answer.):

Appendix

Liver

Skin (don’t know what kind)

Bladder

Lung

Small intestine

Bone

Lymphoma

Soft tissue (muscle or fat)

Brain

Melanoma

Stomach

Breast

Mouth/Tongue/Lip

Testicle

Cervix

Multiple Myeloma

Throat or Pharynx

Colon

Ovary

Thyroid

Esophagus

Pancreas

Uterus

Gallbladder

Prostate

Other-specify: ________________________

Kidney

Rectum

Larynx or Windpipe

Skin (non-melanoma)

Don't know

Leukemia



18. How old were you when this cancer was first diagnosed? years old



19. Was this:

A primary cancer, or

A cancer that had spread or metastasized from somewhere else in the body?



20. What state were you living in when this cancer was first diagnosed? _______________



21. What was the name of the doctor or other health care provider who first diagnosed this cancer? Please provide their name, address, and phone number.


Doctor Name: ____________________________________

Address: ____________________________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________



22. Were you ever hospitalized for treatment of this cancer? If yes, please specify where you were first hospitalized for this cancer.


Yes Name of Hospital: ____________________________________________

Address: ______________________________________________

City: _____________________ State: _____________ Zip Code: _______

No





23. Between the time you were first stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you diagnosed with a second kind of cancer? If yes, what kind of cancer was it? (Mark only one answer.)


Yes

No GO TO QUESTION 30 ON PAGE


Appendix

Liver

Skin (don’t know what kind)

Bladder

Lung

Small intestine

Bone

Lymphoma

Soft tissue (muscle or fat)

Brain

Melanoma

Stomach

Breast

Mouth/Tongue/Lip

Testicle

Cervix

Multiple Myeloma

Throat or Pharynx

Colon

Ovary

Thyroid

Esophagus

Pancreas

Uterus

Gallbladder

Prostate

Other-specify: ________________________

Kidney

Rectum

Larynx or Windpipe

Skin (non-melanoma)

Don't know

Leukemia





24. How old were you when this cancer was first diagnosed? years old



25. Was this:

A primary cancer, or

A cancer that had spread or metastasized from somewhere else in the body?




26. What state were you living in when this second cancer was first diagnosed? ______________



27. What was the name of the doctor or other health care provider who first diagnosed this cancer? Please provide their name, address, and phone number.


Doctor Name: ________________________________________

Address: ____________________________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________







28. Were you ever hospitalized for treatment of this cancer? If yes, please specify where you were first hospitalized for this cancer.


Yes Name of Hospital: _________________________________________

Address: ______________________________________________

City: ___________________State: ____________ Zip Code: ___________

No



29. Between the time you were first stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, have you been diagnosed with any other kind of cancer? If yes, please mark all that apply.

Yes

No GO TO NEXT PAGE


Appendix

Liver

Skin (don’t know what kind)

Bladder

Lung

Small intestine

Bone

Lymphoma

Soft tissue (muscle or fat)

Brain

Melanoma

Stomach

Breast

Mouth/Tongue/Lip

Testicle

Cervix

Multiple Myeloma

Throat or Pharynx

Colon

Ovary

Thyroid

Esophagus

Pancreas

Uterus

Gallbladder

Prostate

Other-specify: ________________________

Kidney

Rectum

Larynx or Windpipe

Skin (non-melanoma)

Don't know

Leukemia





















Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you told by a doctor or other health care provider that you had any of the following conditions?




a. What was the name of the disease?

b. How old were you when you were first told this?

30. Kidney disease or kidney failure? Do not include kidney cancer, kidney stones, bladder infection or incontinence.


Shape3 Yes

No (GO TO Q31)

_________________

_________________


years old

31. Liver disease? Do not include liver cancer.


Shape4 Yes

No (GO TO Q32)


Necrosis

Cirrhosis

Liver failure

Fatty liver

Other–specify:

__________________

__________________


years old

32. Lupus?


Shape5 Yes

No (GO TO Q33)



years old

33. Scleroderma?


Shape6 Yes

No (GO TO Q34)



years old













c. What is the name, address, and phone number of the doctor or other health care provider who diagnosed this condition?


d. Were you ever hospitalized for treatment of this condition?

e. What was the name and address of the hospital where you were first treated for this condition?


Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape7 Yes

No (GO TO Q31)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________
Phone Number: (_____) ____-_______


Shape8 Yes

No (GO TO Q32)


Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape9 Yes

No (GO TO Q33)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape10 Yes

No (GO TO Q34)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________




Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you told by a doctor or other health care provider that you had any of the following conditions?



b. What was the name of the disease?

c. How old were you when you were first told this?

34. Parkinson’s disease?

Shape11 Yes

No (GO TO Q35)



years old

35. Multiple sclerosis (MS)?

Shape12 Yes

No (GO TO Q36)



years old

36. Amyotrophic Lateral Sclerosis (also known as ALS or “Lou Gehrig’s Disease”) or some other motor neuron disease?


Shape13 Yes

No (GO TO Q37)



years old

37. Aplastic anemia?

Shape14 Yes

No (GO TO Q38)



years old









c. What is the name, address, and phone number of the doctor or other health care provider who diagnosed this condition?


d. Were you ever hospitalized for treatment of this condition?

e. What was the name and address of the hospital where you were first treated for this condition?


Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape15 Yes

No (GO TO Q35)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______


Shape16 Yes

No (GO TO Q36)


Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape17 Yes

No (GO TO Q37)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________

Doctor Name: ____________________

Facility: ________________________

Address: ________________________

________________________________

City: ___________________________

State: _____________________

Zip Code: _________________

Phone Number: (_____) ____-_______

Shape18 Yes

No (GO TO Q38)

Name: _______________________

Address: ______________________

_____________________________

City: _________________________

State: ______________________

Zip Code: ____________________




38. Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you told by a doctor or other health care provider that you had a persistent skin rash or dermatitis?

Yes

No GO TO QUESTION 46 ON PAGE XX



38a. Did you have hepatitis at the same time you had the skin rash or dermatitis?

Yes

No



39. What was the name of the skin rash or dermatitis? ________________________________



40. How old were you when you were first told this? years old



41. What is the name, address, and phone number of the doctor or other health care provider who first diagnosed your skin rash or dermatitis?

Doctor’s Name: ____________________________________

Address: ____________________________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________

42. Were you ever hospitalized for treatment of your skin rash or dermatitis? If yes, please specify where you were first hospitalized for this skin rash or dermatitis.


Yes Name of Hospital: _________________________________________

Address: ______________________________________________

City: __________________ State: __________ Zip Code: _____________

No



4Shape19 3. How long did the skin rash last?

number

Days

Weeks

Months

Years












44. Where on your body did the skin rash occur? (Mark all that apply.)


Head

Stomach

Face

Legs

Arms

Feet

Hands

Other-specify:

____________________

Chest

Back




45. What were the symptoms of the skin rash? (Mark all that apply.)


Redness

Blisters

Swelling

Fissures or cracks

Itching

Oozing

Dry skin with scaling/flaking

Bleeding

Crusts

Other–specify: _____________________



46. Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you told by a doctor or other health care provider that you were infertile? (Do not include your partner’s infertility.)


Yes

No GO TO OTHER HEALTH CONDITIONS ON PAGE XX




47. What did your doctor or other health care provider tell you was the reason for your infertility?


Fallopian tube damage or blockage

Abnormal sperm

Endometriosis

Low sperm count

Advanced age

Impotence

Ovulation disorders/Polycystic Ovary

Syndrome (PCOS)

Unexplained infertility

Uterine fibroids/Other uterus problems

Other–specify: ______________________________



48. How old were you when you were first told this? years old










49. What is the name, address, and phone number of the doctor or other health care provider who first diagnosed your infertility?

Doctor Name: ____________________________________

Address: ____________________________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________


50. Were you ever hospitalized for treatment of your infertility? If yes, please specify where you were first hospitalized for this cancer.


Yes Name of Hospital: _________________________________________

Address: ______________________________________________

City: __________________ State: ___________ Zip Code: ___________

No




Other Health Conditions


51. Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, have you had any other serious health problems that have not been covered above? If yes, please list them below.


Yes

1: ____________________________________________________________

2: ____________________________________________________________

3: ____________________________________________________________

No


MALE RESPONDENTS – GO TO OCCUPATIONAL HISTORY SECTION ON PAGE XX


FEMALE RESPONDENTS – CONTINUE WITH REPRODUCTIVE HISTORY SECTION








Reproductive History (WOMEN ONLY)


52. Between the time you were first were stationed, employed, or living at Camp Lejeune or Camp Pendleton and now, were you told by a doctor or other health care provider that you have endometriosis?

Yes

No GO TO QUESTION 56 ON PAGE XX









53. How old were you when you were first told this? years old



54. What is the name, address, and phone number of the doctor or other health care provider who diagnosed your endometriosis?

Doctor Name: ____________________________________

Address: ____________________________________________________________

City: ________________________ State: ________________ Zip Code: _______________

Phone: (_____) ________-____________



55. Were you ever hospitalized for treatment of your endometriosis?


Yes Name of Hospital: _________________________________________

Address: ______________________________________________

City: ___________________ State: ___________ Zip Code: __________

No



56. Have you ever been pregnant?


Yes

No GO TO OCCUPATIONAL HISTORY SECTION ON PAGE XX





57. Have you ever had a pregnancy that resulted in a live birth?


Yes

No





58. Were you pregnant during the time you lived or worked at Camp Lejeune or Camp Pendleton?


Yes

No GO TO OCCUPATIONAL HISTORY SECTION ON PAGE XX












The following questions ask about each pregnancy that occurred during the time that you lived or worked at Camp Lejeune or Camp Pendleton. Please do not include any pregnancies that were not during your time at Camp Lejeune or Camp Pendleton.




59. When did this pregnancy end? (month/year)

60. What was the outcome of this pregnancy?


61. Did this pregnancy involve a birth defect?

Pregnancy #1


/

Live birth of single child

Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape21 Miscarriage or stillbirth


How many weeks were you when the pregnancy ended?

weeks

Did you have a positive pregnancy test before the miscarriage/stillbirth occurred?

Yes No

Was the miscarriage/stillbirth confirmed by a doctor or other health care provider?

Yes No


Shape23 Yes

No



If yes, what is the name of the birth defect?

__________________

__________________

Pregnancy #2



/

Live birth of single child

Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape25 Miscarriage or stillbirth


How many weeks were you when the pregnancy ended?

weeks

Did you have a positive pregnancy test before the miscarriage/stillbirth occurred?

Yes No

Was the miscarriage/stillbirth confirmed by a doctor or other health care provider?

Yes No

Shape27 Yes

No



If yes, what is the name of the birth defect?

__________________

__________________




59. When did this pregnancy end? (month/year)

60. What was the outcome of this pregnancy?


61. Did this pregnancy involve a birth defect?

Pregnancy #3


/


Live birth of single child

Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape29 Miscarriage or stillbirth


How many weeks were you when the pregnancy ended?

weeks

Did you have a positive pregnancy test before the miscarriage/stillbirth occurred?

Yes No

Was the miscarriage/stillbirth confirmed by a doctor or other health care provider?

Yes No



Shape31 Yes

No



If yes, what is the name of the birth defect?

__________________

__________________

Pregnancy #4


/


Live birth of single child

Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape33 Miscarriage or stillbirth

How many weeks were you when the pregnancy ended?

weeks

Did you have a positive pregnancy test before the miscarriage/stillbirth occurred?

Yes No

Was the miscarriage/stillbirth confirmed by a doctor or other health care provider?

Yes No



Shape35 Yes

No



If yes, what is the name of the birth defect?

__________________

__________________











Occupational History


The next questions ask about your work experiences – paid or military – between the time you were first stationed, employed, or living at Camp Lejeune or Camp Pendleton and now. This includes any part-time and full-time jobs, jobs at home, jobs on base, and jobs on a farm that lasted at least one month or longer.


If you never worked, please check this box and go to Question 75 ON PAGE XX.



Job #1


62. Starting with the time you were first stationed, employed or living at Camp Lejeune or Camp Pendleton, what was the name and location of the first company or organization you worked for?


Name of company/organization: _____________________________________________


City: ___________________________________ State: _________________


63. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (that is, address or building number).

_______________________________________________________________



64. In what month and year did you start this job?


/  

m m y y y y

65. In what month and year did you end this job?


/  

m m y y y y

66. What was your job title?


_____________________________________

67. What did that company/organization make or do?


_____________________________________

_____________________________________

68. What were your main activities and duties on this job?


_____________________________________

_____________________________________

_____________________________________

69. Did you usually work part-time or full-time?


Part-time (Part-time is less than 35

hours per week)

Full-time

70. Did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape37 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week





Job #1 (cont.)



71. Did you work with radiation such as x-rays, radar, or microwaves?

Shape38 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


72. Did you work with heavy metals such as lead, mercury, or nickel?

Shape39 Yes

No



What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. Did you work with solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape40 Yes

No



What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week



74. Did you have any other jobs after this one?

Yes GO TO JOB #2

No GO TO QUESTION 75 ON PAGE XX














Job #2



62. What was the name and location of the next company or organization you worked for?


Name of company/organization: _____________________________________________


City: ___________________________________ State: _______________


63. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (that is, address or building number).

_______________________________________________________________



64. In what month and year did you start this job?


/  

m m y y y y

65. In what month and year did you end this job?


/  

m m y y y y

66. What was your job title?


_____________________________________

67. What did that company/organization make or do?

_____________________________________

_____________________________________

68. What were your main activities and duties on this job?


_____________________________________

_____________________________________

_____________________________________

69. Did you usually work part-time or full-time?


Part-time (Part-time is less than 35

hours per week)

Full-time

70. Did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape41 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week






Job #2 (cont.)



71. Did you work with radiation such as x-rays, radar, or microwaves?

Shape42 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


72. Did you work with heavy metals such as lead, mercury, or nickel?

Shape43 Yes

No



What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. Did you work with solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape44 Yes

No



What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week



74. Did you have any other jobs after this one?

Yes GO TO JOB #3

No GO TO QUESTION 75 ON PAGE XX














Job #3



62. What was the name and location of the next company or organization you worked for?


Name of company/organization: _____________________________________________


City: __________________________________ State: ________________


63. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (that is, address or building number).

_______________________________________________________________



64. In what month and year did you start this job?


/  

m m y y y y

65. In what month and year did you end this job?


/  

m m y y y y

66. What was your job title?


_____________________________________

67. What did that company/organization make or do?


_____________________________________

_____________________________________

68. What were your main activities and duties on this job?


_____________________________________

_____________________________________

_____________________________________

69. Did you usually work part-time or full-time?


Part-time (Part-time is less than 35

hours per week)

Full-time

70. Did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape45 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week






Job #3 (cont.)



71. Did you work with radiation such as x-rays, radar, or microwaves?

Shape46 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


72. Did you work with heavy metals such as lead, mercury, or nickel?

Shape47 Yes

No



What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. Did you work with solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape48 Yes

No



What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week



74. Did you have any other jobs after this one?

Yes GO TO JOB #4

No GO TO QUESTION 75 ON PAGE XX














Job #4



62. What was the name and location of the next company or organization you worked for?


Name of company/organization: _____________________________________________


City: ___________________________________ State: ________________



63. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (that is, address or building number).

_______________________________________________________________



64. In what month and year did you start this job?


/  

m m y y y y

65. In what month and year did you end this job?


/  

m m y y y y

66. What was your job title?


_____________________________________

67. What did that company/organization make or do?


_____________________________________

_____________________________________

68. What were your main activities and duties on this job?


_____________________________________

_____________________________________

_____________________________________

69. Did you usually work part-time or full-time?


Part-time (Part-time is less than 35

hours per week)

Full-time

70. Did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape49 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week





Job #4 (cont.)



71. Did you work with radiation such as x-rays, radar, or microwaves?

Shape50 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour. hours per week


72. Did you work with heavy metals such as lead, mercury, or nickel?

Shape51 Yes

No



What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. Did you work with solvents like paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape52 Yes

No



What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week



74. Did you have any other jobs after this one?

Yes GO TO JOB #5

No GO TO QUESTION 75 ON PAGE XX


Job #5



62. What was the name and location of the next company or organization you worked for?


Name of company/organization: _____________________________________________


City: __________________________________ State: ________________


63. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (that is, address or building number).

_______________________________________________________________



64. In what month and year did you start this job?


/  

m m y y y y

65. In what month and year did you end this job?


/  

m m y y y y

66. What was your job title?


_____________________________________

67. What did that company/organization make or do?


_____________________________________

_____________________________________

68. What were your main activities and duties on this job?


_____________________________________

_____________________________________

_____________________________________

69. Did you usually work part-time or full-time?


Part-time (Part-time is less than 35

hours per week)

Full-time

70. Did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape53 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week






Job #5 (cont.)



71. Did you work with radiation such as x-rays, radar, or microwaves?

Shape54 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour. hours per week


72. Did you work with heavy metals such as lead, mercury, or nickel?

Shape55 Yes

No




What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. Did you work with solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape56 Yes

No




What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week



74. Did you have any other jobs after this one?

Yes GO TO OTHER JOBS

No GO TO QUESTION 75 ON PAGE XX













Other Jobs


Please answer the following questions about all of the other jobs you have held since the last job you just reported.



70. In any of these jobs, did you work with pesticides, herbicides, fungicides, insecticides, or rat poison?

Shape57 Yes

No



What is the name of the chemical(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


71. In any of these jobs, did you work with radiation such as x-rays, radar, or microwaves?

Shape58 Yes

No



What kind of radiation did you work with? ___________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


72. In any of these jobs, did you work with heavy metals such as lead, mercury, or nickel?

Shape59 Yes

No



What is the name of the metal(s) you worked with?

__________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week


73. In any of these jobs, did you work with solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Shape60 Yes

No



What is the name of the solvent(s) you worked with?

____________________________________


On average, how many hours per week were you around these products? Enter ‘00’ if less than 1 hour.

hours per week







75. Were you stationed in Vietnam between 1965 and 1971?

Yes

No GO TO SMOKING HISTORY SECTION BELOW



76. Which year(s) were you in Vietnam? (Mark all that apply.)

1965 1969

1966 1970

1967 1971

1968



77. In total, how many months were you in Vietnam between 1965 and 1971?


months



78. Did you ever come into contact with herbicides while you were in Vietnam? For example, did you inhale herbicides or get herbicides on your skin or clothing?


Yes (describe how you were exposed)

______________________________________________________

______________________________________________________

No

Not sure




Smoking History



79. Have you ever smoked cigarettes regularly?

Yes

No GO TO QUESTION 86 ON PAGE XX




80. Do you smoke cigarettes now?

Yes

No GO TO QUESTION 83 ON PAGE XX




81. On average, over all the years you have smoked, how many cigarettes a day did you smoke (1 pack=20 cigarettes)?

cigarettes per day








82. In total, how many years have you smoked, excluding any times you may have quit?

years – GO TO QUESTION 86 ON PAGE XX




83. How old were you the last time you quit smoking cigarettes? years old




84. On average, when you were smoking, about how many cigarettes a day did you smoke (1 pack = 20 cigarettes)?

cigarettes per day




85. In total, how many years did you smoke, excluding any times you may have quit?

years




86. Have you ever used any other tobacco products regularly (such as chewing tobacco, smokeless tobacco, cigars, a pipe, etc.)?

Yes

No GO TO QUESTION 89




87. Do you currently use these tobacco products regularly?

Yes

No



88. Which of the following tobacco products have you used or do you currently use on a regular basis? (Mark all that apply.)

Chewing tobacco

Smokeless tobacco

Pipe

Cigars

Other-specify: ________________________________



89. Have you ever lived for more than 1 year with someone who smoked on a daily basis?

Yes

No GO TO ALCOHOL HISTORY SECTION ON PAGE XX








90. How many years did you live with someone who smoked on a daily basis?

1-3 years 7-9 years 13-15 years

4-6 years 10-12 years 16 or more years



91. During most of this time, how many people living with you smoked on a daily basis?

1 person

2 persons

More than 2 persons




Alcohol History


The following questions relate to your use of alcohol.


92. Have you ever had a drink of alcohol?

Yes

No GO TO DEMOGRAPHICS SECTION ON PAGE XX



93. At what age did you start drinking alcohol? years old



94. Do you drink alcoholic beverages now?

Yes

No GO TO QUESTION 98 ON PAGE XX



95. On average, how often do you drink alcoholic beverages? (Mark one.)

Almost every day

2 to 4 times a week

1 time a week

1 to 3 times a month

Less than once a month



A “serving” of alcohol equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.



96. When you drink, about how many servings do you usually have?

servings









97. Is there a time in the past that you drank significantly more than you usually drink now?

Shape61 Yes

No GO TO DEMOGRAPHICS




98. How old were you when you stopped drinking alcoholic beverages? years old




99. On average, how often did you drink alcoholic beverages? (Mark one.)

Almost every day

2 to 4 times a week

1 time a week

1 to 3 times a month

Less than once a month




100. When you drank, about how many servings did you usually have?

servings




Demographics


A. What race do you consider yourself to be? (Mark all that apply.)

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Some other race–specify: ___________________________________



B. Do you consider yourself to be Hispanic or Latino?

Yes

No



C. What is the highest level of education you have completed? (Mark one.)

Less than a high school diploma

High school diploma or GED

Some college, Technical/Vocational School, or Associate’s Degree

Bachelor’s degree (4 years of college) or higher




D. What is your Social Security Number (SSN)? - -

(The authority for collecting your SSN is the National Defense Authorization Act for Fiscal Year 2008. Your SSN will be kept private. We do not plan to share this information with anyone other than ATSDR staff. We will use your SSN for identity verification purposes and to link with your medical data.)


Please provide your:

Home Phone Number: (__ _ _) - _ _ _ - _ _ _ _ N/A

Cell Phone Number: (_ _ _) - _ _ _ - _ _ _ _ N/A

E-Mail address: _____________________________________________________


Please provide the contact information of a friend or family member who will always know your whereabouts in case we need to contact you in the future.


First Name: _________________________ Last Name: _________________________


Street Address: _________________________________________ Apartment Number: _______

City: _____________________ State: __________________ Zip code: _ _ _ _ _ - _ _ _ _ Country: _____________________________

Home Phone Number: (_ _ _) - _ _ _ - _ _ _ _ N/A

Cell Phone Number: (_ _ _) - _ _ _ - _ _ _ _ N/A


Relationship to you (sibling, child, friend, etc.): ______________________________________

























Conclusion

The Agency for Toxic Substances and Disease Registry (ATSDR) would like to sincerely thank you for your time and effort. Your contributions to this important health survey will help us learn more about ways to improve health and prevent disease in the future.


Please help us by reviewing each page again to make sure that you:

  • Did not skip any questions, and

  • Marked out any wrong answers and entered an X next to the correct answer.


If you’ve answered “Yes” to any of the conditions listed below, please read and sign the Medical Release Form included in this package, so we can obtain your medical records from your doctor or health care provider to confirm this condition.

  • Any cancer

  • Parkinson’s disease

  • Kidney disease or Kidney failure

  • Liver disease

  • Lupus

  • Aplastic anemia

  • Persistent skin rashes or dermatitis

  • Scleroderma

  • Infertility

  • Endometriosis

  • Multiple Sclerosis (MS)

  • Amyotrophic Lateral Sclerosis (ALS)



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleQuestions for the health survey
AuthorPerri Ruckart
File Modified0000-00-00
File Created2021-02-01

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