attachment C survey 11_10 clean

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?

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

4. 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

10. 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.

Where were you living? (Please mark one.)	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.

15. 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. Yes No (GO TO Q31)	_________________ _________________	years old
31. Liver disease? Do not include liver cancer. Yes No (GO TO Q32)	Necrosis Cirrhosis Liver failure Fatty liver Other–specify: __________________ __________________	years old
32. Lupus? Yes No (GO TO Q33)		years old
33. Scleroderma? 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: (_____) ____-_______	Yes No (GO TO Q31)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	Yes No (GO TO Q32)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	Yes No (GO TO Q33)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	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? Yes No (GO TO Q35)		years old
35. Multiple sclerosis (MS)? 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? Yes No (GO TO Q37)		years old
37. Aplastic anemia? 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: (_____) ____-_______	Yes No (GO TO Q35)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	Yes No (GO TO Q36)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	Yes No (GO TO Q37)	Name: _______________________ Address: ______________________ _____________________________ City: _________________________ State: ______________________ Zip Code: ____________________
Doctor Name: ____________________ Facility: ________________________ Address: ________________________ ________________________________ City: ___________________________ State: _____________________ Zip Code: _________________ Phone Number: (_____) ____-_______	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

4 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 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	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 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	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 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	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 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	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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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?

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)