2 Baseline

National Institute of Environmental Health Sciences (NIEHS)

01/20/11

Home Visit Baseline Scripts and
Questionnaires

OMB#0925-XXX
EXP:xx/xxxx

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Table of Contents
Home Visit Baseline Scripts and Questionnaires.............................................1 
Part 4: Scripts and Administrative Modules -Pre-Home Visit Questionnaire
(Estimated Burden: 55 minutes)..............................................................3 
SECTION A: Scheduling Call..............................................................................4 
SECTION B: Home Visit Confirmation Call .....................................................10 
SECTION C: Consent ........................................................................................15 
SECTION D: Home Visit Specimen Collection Checklist and HVA notes....16 
Part 5: Home Visit Questionnaire (Estimated Burden: Shortest Path = 31
minutes; Longest Path = 66 minutes) ...................................................29 
SECTION E: Clean-up Related Tasks and Exposures During Clean-up .......30 
SECTION F: Health ............................................................................................32 
SECTION G: Access to Healthcare ..................................................................47 
SECTION H: Family Medical History................................................................48 
SECTION I: Mental Health.................................................................................55 
SECTION K: Non-occupational Exposures .....................................................64 
SECTION L: Lifestyle ........................................................................................65 
SECTION M: Residential History......................................................................66 
SECTION N: Experiences with Hurricane Katrina ..........................................68 
SECTION O: Physical Activity..........................................................................71 
Part 6: Scripts and Administrative Modules Post-Home Visit Questionnaire
(Estimated Burden: 1 minute)................................................................77 
SECTION R: Conclusion of Home Visit ...........................................................78 
Section S: Medical Referral ..............................................................................79 
SECTION T: Incident Report.............................................................................80 
SECTION U: Follow-up Calls ............................................................................81 
SECTION V: Shipping .......................................................................................82 

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Part 4: Scripts and Administrative Modules Pre-Home Visit Questionnaire (Estimated
Burden: 55 minutes)

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SECTION A: Scheduling Call
SECTION A.1: Initial Contact
SECTION A.1.a: Voicemail Script:
Hello, this message is for [PARTICIPANT’S NAME] and I’m calling about the Gulf Longterm Follow-up Study (GuLF Study), sponsored by the National Institutes of Health. We
would like to speak with you about participating in this important study. We will try to
contact you again soon. Thank you.
Section A.1.b: Contact Script
Hello, I am with the Gulf Long-term Follow-up Study (GuLF Study). May I please speak
to [PARTICIPANT’S FULL NAME]?
[INTERVIEWER: DOES THE PARTICIPANT SPEAK ENGLISH? ATTEMPT
TO FIND AN ENGLISH SPEAKER IN THE HOUSEHOLD TO CONFIRM
THAT THE TARGET RESPONDENT DOES NOT SPEAK ENGLISH AND TO
SCHEDULE A CALL BACK TO BE CONDUCTED IN THE PARTICIPANT’S
LANGUAGE]
1. PARTICIPANT SPEAKS ENGLISH – CONTINUE WITH A.2
2. PARTICIPANT DOES NOT SPEAK ENGLISH – CALL BACK
SCHEDULED, LANGUAGE FLAG SET – CONTINUE WITH A.2
3. PARTICIPANT DOES NOT SPEAK ENGLISH – SOFT APPOINTMENT
CALL BACK SCHEDULED, LANGUAGE FLAG SET – CONTINUE
4. PARTICIPANT DOES NOT SPEAK ENGLISH AND REFUSES – HARD
REFUSAL - GO TO SECTION A.5
5. INTERVIEWER: IF THE PERSON IS UNABLE TO BE REACHED, REFER
TO TRACING – GO TO SECTION A.5

I am sorry I missed [HIM/HER/NAME]. What is the best time to reach
[HIM/HER/NAME]?
DATE: ___/____/_____ [DD/MM/YYYY] [CALENDAR]
TIME OF DAY: _/_/ [AM/PM]
[TERMINATE CALL]

SECTION A.2: Introduction to the Home Visit

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[IF PARTICIPANT INITIALLY ANSWERED THE PHONE]
My name is [INTERVIEWER NAME]. When we spoke with you previously on [DATE],
you agreed to participate in the next phase of this study. I am calling to schedule your
appointment for the home visit.
Are you in a place where you can safely talk on the phone and answer my questions?
Yes ......................... 1 [GO TO CONTINUE FOR ALL PARTICIPANTS
No........................... 2
I will attempt to contact you again soon. Thank you for your time.
[IF PARTICIPANT DID NOT INITIALLY ANSWER THE PHONE]
My name is [INTERVIEWER NAME] and I am with the Gulf Long-term Follow-up Study
(GuLF Study). When we spoke with you previously on [DATE], you agreed to participate
in the next phase of this study. I am calling to schedule your appointment for the home
visit.
Are you in a place where you can safely talk on the phone and answer my questions?
Yes ......................... 1 [GO TO CONTINUE FOR ALL PARTICIPANTS]
No........................... 2
I will attempt to contact you again soon. Thank you for your time.

[CONTINUE FOR ALL PARTICIPANTS]

During the visit, you’ll be asked to:
• have your blood pressure, height, weight, hips, and waist measured
• blow into a machine to measure your lung function. If you are using an inhaler
because of a lung condition, we ask that you not use the inhaler on the day of
your home visit prior to the lung function test, if you are able to go without the
medication for a short period of time
• have a blood sample drawn and provide samples of urine, hair, and toenails
• complete a one-hour interview
• and allow our staff to collect a dust sample from your home
The visit will take place in your home and last about two and a half hours. You’ll receive
a $50 gift card for completing the home visit
A1. Do you have any questions about the home visit?
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[IF YES, RESPOND TO CONCERNS BASED ON INFORMATION IN THE FAQ;
IF NO, GO TO SECTION A.3]
[IF PARTICIPANT AGREES TO PARTICIPATE, GO TO SECTION A.3;
IF PARTICIPANT ASKS FOR TIME TO CONSIDER, GO TO SECTION A.4;
IF REFUSAL AND A REASON IS GIVEN; GO TO SECTION A.5.a;
IF REFUSAL AND A REASON IS NOT GIVEN; GO TO SECTION A.5.b]

SECTION A.3: Scheduling the Home Visit
What would be a good date and time for you to complete the home visit?
[INTERVIEWER: RECORD DATE AND TIME]
DATE: ___/____/_____ [DD/MM/YYYY]
TIME OF DAY: __/__/ [AM/PM]
I would also like to confirm your address to make sure we have it correct for the
appointment, and so that we can send you some items in the mail before our visit.
A2. Is your mailing address [RESPONDENT’S ADDRESS]?
Yes…………….1 [SKIP A2a]
No………………2
A2a. What is your mailing address?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
A3. Is this the same address for the home visit?
Yes ......................... 1 [GO TO SCRIPTS BELOW]
No........................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
A3a. What is the address for the home visit?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
A3b. Is this where you live?
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Yes .........................1
No...........................2
DON’T KNOW ........8
REFUSED ..............9
Great! Thank you. Before the visit we will mail you a package that includes the following
items:
• A list of frequently asked questions with answers
• An Informed Consent packet which is a document that explains the details of the
GuLF Study and explains what you can expect during the home visit
• A shorter summary page that gives you a quick overview of the Informed
Consent packet
• A urine collection container with instructions and a label
The package will also contain instructions for you to prepare for the visit. When you get
the package, please go ahead and open it and read the information provided
[INTERVIEWER: IF THE PARTICIPANT TELLS YOU THAT HE/SHE CANNOT READ,
SAY: That is ok. When the package arrives give me a call and I will talk you through it.
My number is [INTERVIEWER’S PHONE NUMBER]. Please try not eat or drink
anything for eight hours before the visit. Also, collect all of your current prescription or
over-the-counter medications so that we can note them during the home visit. A urine
collection container will be enclosed and it is important that you collect your first urine of
the day on the day of the appointment. Please call us if you have any questions or
concerns about the information that you receive, or if you do not receive any materials
within the next few days.
Do you have any questions?
[IF YES, RESPOND TO CONCERNS BASED ON INFORMATION IN THE FAQ]

I will give you a reminder call before the scheduled visit to confirm that the time still
works for you.
In the meantime, if you have any questions or if something comes up and you need to
reschedule the visit, please call the study toll-free phone number at 1 855 NIH GuLF
(644 4853) between the hours of [9 AM and 9 PM] and Sunday between the hours of
[12pm and 6pm] [CALL CENTER HOURS PRESENTED IN LOCAL TIME].
Thank you. We look forward to seeing you soon.
[TERMINATE CALL]

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SECTION A.4: Schedule Call to Reconsider Participation
We appreciate your willingness to consider taking part in the study. When would be a
convenient time to call you back to speak with you about the study?
[RECORD DATE AND TIME]
DATE: ___/____/_____ [DD/MM/YYYY]
TIME OF DAY : __/__/ [AM/PM]
Thank you. We’ll call you then. In the meantime, if you have any questions or would
like to speak with us about the study sooner, please call the study toll-free phone
number at 1 855 NIH GuLF (644 4853) between the hours of [9 AM and 9 PM] and
Sunday between the hours of [12pm and 6pm] [CALL CENTER HOURS PRESENTED
IN LOCAL TIME].
[TERMINATE CALL]

SECTION A.5: Refusal to Participate
SECTION A.5.a. I understand you said…
[INTERVIEWER: RESTATE REASONS AND USE TELEPHONE INTERVIEW
Q & A BENEFITS TO ATTEMPT A CONVERSION]

If you don't mind, I'd like to make a note of why you are not continuing. This
information will help us improve the GuLF Study.
[RECORD REASON]
[PARTICIPANT’S NAME], I really appreciate your time. If you have any questions
or concerns, let me give you the phone number to reach a member of the study
staff who will be able to assist you. That toll-free number is 1 855 NIH GuLF (644
4853), and you may call Monday through Saturday between the hours of [9 AM
and 9 PM] and Sunday between the hours of [12pm and 6pm] [CALL CENTER
HOURS PRESENTED IN LOCAL TIME].
[TERMINATE CALL]
SECTION A.5.b: May I ask why you do not want to participate at this time? This
information will help us improve the GuLF Study.
[INTERVIEWER: RESTATE REASON AND USE TELEPHONE INTERVIEW
Q & A BENEFITS TO ATTEMPT A CONVERSION]
[RECORD REASON]
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[PARTICIPANT’S NAME], I really appreciate your time. If you have any questions
or concerns, let me give you the toll-free phone number to reach a member of the
study staff who will be able to assist you. That toll-free phone number is 1 855
NIH GuLF (644 4853), and you may call Monday through Saturday between the
hours of [9 AM and 9 PM] and Sunday between the hours of [12pm and 6pm]
[CALL CENTER HOURS PRESENTED IN LOCAL TIME].
[TERMINATE CALL]

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SECTION B: Home Visit Confirmation Call
SECTION B.1.a: Voicemail Script
Hello, this message is for [PARTICIPANT’S NAME] and I’m calling about the Gulf
Long-term Follow-up Study (GuLF Study), sponsored by the National Institutes of
Health. We would like to speak with you about participating in this important
study. We will try to contact you again soon. Thank you.
SECTION B.1.b: Contact Script
Hello, I am with the Gulf Long-term Follow-up Study (GuLF Study). May I please
speak to [PARTICIPANT’S FULL NAME]?
YES........................ 1 [GO TO SECTION B.1]
NOT HERE ............ 3 [CONTINUE]
I am sorry I missed [HIM/HER/NAME]. What is the best time to reach
[HIM/HER/NAME]?
DATE : __/__/_____[MM/DD/YYYY] [CALENDAR]
TIME: _/_/ [AM/PM]
DATE2 : __/__/_____[MM/DD/YYYY] [CALENDAR]
TIME: _/_/ [AM/PM]
Thank you. I will call you back then.

[TERMINATE CALL]
SECTION B.1.c: Confirmation of Home Visit
[IF PARTICIPANT INITIALLY ANSWERED THE PHONE]

Good [MORNING], [PARTICIPANT’S NAME]. My name is [INTERVIEWER
NAME]. Thank you very much for agreeing to participate in a home visit for the
GuLF Study.
Are you in a place where you can safely talk on the phone and answer my
questions?
Yes......................... 1 [GO TO CONTINUE FOR ALL PARTICIPANTS]
No .......................... 2
I will attempt to contact you again soon. Thank you for your time.
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[IF PARTICIPANT DID NOT INITIALLY ANSWER THE PHONE]
Good [MORNING], [PARTICIPANT’S NAME]. My name is [INTERVIEWER
NAME] and I am with the Gulf Long-term Follow-up Study (GuLF Study). Thank
you very much for agreeing to participate in a home visit for the GuLF Study.
Are you in a place where you can safely talk on the phone and answer my
questions?
Yes......................... 1 [GO TO CONTINUE FOR ALL PARTICIPANTS]
No .......................... 2
I will attempt to contact you again soon. Thank you for your time.

[CONTINUE FOR ALL PARTICIPANTS]

I have you scheduled for a visit on [DATE] at [TIME]. Does that time still work for
you?
Yes......................... 1
No .......................... 2 [GO TO SECTION B.4]
DON’T KNOW........ 3 [GO TO SECTION B.3]

SECTION B.2: Conclusion of Home Visit Confirmation
Great, I look forward to seeing you then. I would like to confirm your address.
B1. Is the correct address for the home visit [PARTICIPANT’S ADDRESS]?
Yes…………….1 [GO TO QUESTION B2]
No………………2
B1a. What is the address for the home visit?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
B1b. Do you live at this address?
Yes......................... 1 [GO TO QUESTION B2]
No .......................... 2

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B1c. What is the address where you live?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
DON’T KNOW ........ 8
REFUSED .............. 9
[
B2. Did you receive the study materials in the mail?
Yes…………….1 IF YES: [INTERVIEWER: Great! Please hold onto the materials
until the appointment.]
No………………2 [INTERVIEWER: I will bring the materials with me on the day
of the visit.
Please make sure that you have placed one of the labels on the urine collection
container that you will be using to collect your first urine of the day. If you are
using an inhaler because of a lung condition, we ask that you not use the inhaler
for your [morning] dose on the day of your home visit prior to the lung function
test, if you are able to go without the medication for a short period of time. Please
try not eat or drink anything for eight hours before the visit. Also, collect your
current prescription and over-the-counter medications so that we can note them
during the home visit.
B3. Do you have any questions for me?
[IF YES, RESPOND TO CONCERNS BASED ON INFORMATION IN THE
FAQ]

If you need to reach me before my visit, please call me at [INTERVIEWER
PHONE NUMBER] or the GuLF Study Hotline at 1 855 NIH GuLF (644 4853).
Thank you. I look forward to meeting with you soon!
[TERMINATE CALL]

SECTION B.3: Tentative Home Visit Confirmation
It sounds like you are unsure whether this is a convenient time for the home visit.
Unless I hear otherwise from you, I will plan to arrive at your home on [DATE] at
[TIME]. If you feel that you do need to reschedule, please let me know as soon
as possible and I will be happy to set up an appointment time that better fits your
schedule.
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Before we go, I would like to confirm your address.
B4. Is the correct address for the home visit [PARTICIPANT’S ADDRESS]?
Yes…………….1 [GO TO QUESTION B5]
No………………2
B4a. What is the address for the home visit?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
B4b. Do you live at this address?
Yes......................... 1 [GO TO QUESTION B5]
No .......................... 2
B4c. What is the address where you live?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
DON’T KNOW ........ 8
REFUSED .............. 9
B5. Did you receive the study materials in the mail?
Yes…………….1 IF YES: [INTERVIEWER: Great! Please hold onto the materials
until the appointment.]
No………………2 [INTERVIEWER: I will bring the materials with me on the day
of the visit.
Great. You can reach me at [INTERVIEWER PHONE NUMBER] or you may call
the GuLF Study Hotline at 1 855 NIH GuLF (644 4853). If I do not hear back from
you I will be there on [DATE] at [TIME] for the home visit.
Thank you! I look forward to meeting with you soon!
[TERMINATE CALL]

SECTION B.4: Reschedule Home Visit

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Let’s see if we can find a time that is more convenient for you to complete the
home visit. When would be a better date and time for you?
DATE : __/__/_____[MM/DD/YYYY]
TIME: _/_/ [AM/PM]
OK great! I am glad we could reschedule. Your participation is important to us
and we really appreciate your time. I also would like to confirm your address and
that you received the home visit materials in the mail.
B6. Is the correct address for the home visit [PARTICIPANT’S ADDRESS]?
Yes…………….1 [GO TO QUESTION B7]
No………………2
B6a. What is the address for the home visit?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
B6b. Do you live at this address?
Yes......................... 1 [GO TO QUESTION B7]
No .......................... 2
B6c. What is the address where you live?
House number: _______________________[FREE TEXT FIELD]
Street name: _________________________[FREE TEXT FIELD]
Apartment number: ___________________[FREE TEXT FIELD]
City: __________________________[FREE TEXT FIELD]
State: _______________[STATE DROP DOWN BOX]
DON’T KNOW ........ 8
REFUSED .............. 9
B7. Did you receive the study materials in the mail?
Yes…………….1 IF YES: [INTERVIEWER: Great! Please hold onto the materials
until the appointment.]
No………………2 [INTERVIEWER: I will bring the materials with me on the day
of the visit.
Thank you for your time. If you have any questions or concerns before your visit
you can reach me at [INTERVIEWER PHONE NUMBER] or you may call the
GuLF Study Hotline at 1 855 NIH GuLF (644 4853).
We look forward to seeing you then.
[TERMINATE CALL]

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SECTION C: Consent
C1. INFORMED CONSENT PROCEDURES COMPLETED?
YES ............. 1 VERSION # _______
NO ............... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD]
C2. CONSENT TO SHARE INFORMATION WITH HEALTH CARE PROVIDER?
YES ...................................................................................................1 VERSION # ____
NO. PARTICIPANT HAS HEALTH CARE PROVIDER, BUT DOES NOT WANT
INFORMATION SHARED..................................................................2 [GO TO C3]
NO. PARTICIPANT DOES NOT HAVE HEALTH CARE PROVIDER3 [GO TO C3]
C2.a. NAME AND CONTACT INFORMATION FOR PARTICIPANT’S DOCTOR OR
HEALTHCARE PROVIDER:
DOCTOR NAME ____________________________ [FREE TEXT FIELD]
PRACTICE NAME ___________________________ [FREE TEXT FIELD]
ADDRESS _________________________________ [FREE TEXT FIELD]
CITY ______________________________________ [FREE TEXT FIELD]
STATE ____________________________________ [FREE TEXT FIELD]
ZIP CODE _________________________________ [FREE TEXT FIELD]
PHONE ___________________________________ [FREE TEXT FIELD]
C3. CONSENT TO PROVIDE A REFERRAL FOR MEDICAL OR MENTAL HEALTH
CARE?
YES ............. 1 VERSION # ____
NO ............... 2
C4. CONSENT TO OBTAIN PRE-EMPLOYMENT MEDICAL EXAM?
YES ............. 1 VERSION # ____
NO ............... 2
C4a. RELEASE FORM COMPLETED?
YES... 1 VERSION # ____
NO .... 2

[PROGRAMMER: ONLY FOR THOSE IDENTIFIED]
C5. CONSENT FOR ADDITIONAL SAMPLE COLLECTION?
YES ............. 1 VERSION # _____
NO ............... 2

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SECTION D: Home Visit Specimen Collection Checklist and HVA notes
[INTERVIEWER: USE THIS SECTION TO RECORD SPECIMEN DATA]
D1. RECORD THE IDENTIFICATION NUMBER OF THE HOME VISIT KIT USED
FOR THIS VISIT.
[__ __ __ __ __ __ __]
D2. RECORD THE HOME VISIT AGENT ID. [AUTOPOPULATED]
[__ __ __ __ __ __]
D3. DID THE PARTICIPANT COLLECT A FIRST MORNING URINE SAMPLE?
YES ... 1
NO ..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO QUESTION
D3c]
D3a. RECORD THE TIME THE FIRST MORNING SPECIMEN WAS
COLLECTED.
__/__/ : __/__/
AM ....... 1
PM ....... 2
D3b. RECORD THE VOLUME OF THE COLLECTED FIRST MORNING
SPECIMEN.
__/__/__/ ML [GO TO QUESTION D4]
D3c. IF A FIRST MORNING URINE SAMPLE WAS NOT COLLECTED, WAS A
RANDOM URINE SPECIMEN COLLECTED DURING THE VISIT?
YES...... 1
NO ....... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D6]
D3c.1. RECORD THE TIME THE RANDOM URINE SPECIMEN WAS
COLLECTED.
__/__/ : __/__/
AM..... 1
PM..... 2
D3c.2. RECORD THE VOLUME OF THE RANDOM URINE
COLLECTED SPECIMEN.
__/__/__/ ML

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D4. [PROGRAMMER NOTE: THIS IS ONLY SHOWN FOR BIOMEDICAL
SUBCOHORT] WAS AN ALIQUOT REMOVED FOR LABORATORY URINALYSIS
TESTING?
YES ............. 1
NO ............... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD]
D5. WAS AN ALIQUOT REMOVED FOR DIPSTICK TESTING?
YES ............. 1
NO ............... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D6]
D5a. URINE GLUCOSE LEVEL
[PULL DOWN MENU WITH DIPSTICK LEVELS AS INDICATED ON PACKAGE]

D5b. Have you previously been diagnosed with diabetes?
YES ............. 1
NO............... 2
D5b.1. In the last month have you experienced frequent urination or
unusual thirst?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9

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D5c. CONFIRM INTERPRETATION AND ADVICE
1. URGENT. SEE YOUR HEALTH CARE PROVIDER WITHIN THE
NEXT WEEK TO HAVE YOUR GLUCOSE LEVELS CHECKED AGAIN.
2. OF POTENTIAL CONCERN. SEE YOUR HEALTH CARE
PROVIDER WITHIN THE NEXT MONTH TO HAVE YOUR GLUCOSE
LEVELS CHECKED AGAIN OR SOONER IF YOUR SYMPTOMS
APPEAR OR WORSEN.
3. NORMAL. NO FOLLOW-UP ACTION IS REQUIRED. [SKIP TO D6]
D5d. DOCUMENTATION OF REFERRAL
OFFERED, ACCEPTED, PROVIDED............... 1
OFFERED, ACCEPTED, CASE REFERRED
TO CALL CENTER FOR ASSISTANCE ........... 2
OFFERED, DECLINED .................................... 3
NO REFERRAL OFFERED .............................. 4

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D6. RECORD PARTICIPANT’S HEIGHT TO THE NEAREST TENTH.
D6a. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D6b. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D6c. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D6d. RECORD METHOD OF COLLECTION
MEASURED STANDING........................1
MEASURED SITTING ............................2
SELF-REPORTED .................................3
D6e. HEIGHT AVERAGE [CAPI: INSERT HEIGHT AVERAGE
CALCULATION FROM D6a, D6b, AND D6c AND CALCULATE
CONVERSION TO INCHES FOR PARTICIPANT REPORTING]
I_I_I_I CM
I_I_I_I INCHES CONVERSION

D7. RECORD PARTICIPANT’S WEIGHT.
D7a I_I_I_I KG
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D7b. I_I_I_I KG
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D7c. I_I_I_I KG
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999

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D7d. RECORD METHOD OF COLLECTION
MEASURED ...........................................1
SELF-REPORTED .................................2
D7e. WEIGHT AVERAGE [CAPI: INSERT AVERAGE CALCULATION FROM
D7a, D7b, AND D7c AND CALCULATE CONVERSION TO LBS FOR
PARTICIPANT REPORTING]
I_I_I_I KG
I_I_I_I LBS
D8. RECORD PARTICIPANT’S BMI. [CAPI: INSERT BMI CALCULATION FROM
D6e AND D7e]
I_I_I BMI
D8a. CONFIRM OF INTERPRETATION AND ADVICE
1. OBESE. YOU SHOULD TALK TO YOUR HEALTH CARE PROVIDER
ABOUT THIS FINDING AND ANY NEED FOR ADDITIONAL
EVALUATION OR CONSULTATION.
2. OVERWEIGHT. YOU SHOULD TALK TO YOUR HEALTH CARE
PROVIDER ABOUT THIS FINDING AND ANY NEED FOR ADDITIONAL
EVALUATION OR CONSULTATION.
3. NORMAL. MAINTAINING A HEALTHY WEIGHT MAY REDUCE THE
RISK OF CHRONIC DISEASES ASSOCIATED WITH OVERWEIGHT
AND OBESITY.
4. UNDERWEIGHT. TALK WITH YOUR HEALTH CARE PROVIDER TO
DISCUSS THIS FINDING AND ANY NEED FOR ADDITIONAL
EVALUATION OR CONSULTATION.
5. COULD NOT BE CALCULATED
D9. RECORD PARTICIPANT’S WAIST CIRCUMFERENCE.
D9a. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D9b. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D9c. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999

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D10. RECORD PARTICIPANT’S HIP CIRCUMFERENCE.
D10a. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D10b. I_I_I_I CM
NOT OBTAINED............... 7 77 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D10c. I_I_I_I CM
NOT OBTAINED............... 777 PLEASE PROVIDE A REASON: [FREE TEXT
FIELD]
REFUSED ........................ 999
D11. RECORD PARTICIPANT’S BLOOD PRESSURE. [CAPI: SET
WARNING FLAG: IF SYSTOLIC BP ≥ 180 OR DIASTOLIC BP ≥ 110, THEN
GO TO D11e; INTERVIEWER: FOLLOW PROTOCOL AND THEN END
INTERVIEW]
D11a. I_I_I_I / I_I_I_I
D11a.1 HEART RATE __________
NOT OBTAINED............... 777 777 PLEASE PROVIDE A REASON: [FREE
TEXT FIELD]
REFUSED ........................ 999 999
D11b I_I_I_I / I_I_I_I
D11b.1 HEART RATE __________
NOT OBTAINED............... 777 777 PLEASE PROVIDE A REASON: [FREE
TEXT FIELD]
REFUSED ........................ 999 999
D11c I_I_I_I / I_I_I_I
D11c.1 HEART RATE __________
NOT OBTAINED............... 777 777 PLEASE PROVIDE A REASON: [FREE
TEXT FIELD]
REFUSED ........................ 999 999
D11d AVERAGE (CALCULATION BASED ON D11b AND D11c)
I_I_I_I / I_I_I_I
NOT OBTAINED............... 777 777 PLEASE PROVIDE A REASON: [FREE
TEXT FIELD]

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D11e. CONFIRM OF INTERPRETATION AND ADVICE
1. SYSTOLIC BP ≥ 180 OR DIASTOLIC BP ≥ 110. CALL 911 OR GO TO
THE EMERGENCY DEPARTMENT IMMEDIATELY. EMERGENCY CARE
NEEDED. [COMPLETE INCIDENT REPORT]
2. SYSTOLIC BP ≥ 180 OR DIASTOLIC BP ≥ 110. PARTICIPANT
REFUSED 911 CALL AND ASSISTANCE WITH EMERGENCY CARE.
[COMPLETE INCIDENT REPORT]
3. SYSTOLIC BP 160 TO 179 OR DIASTOLIC BP 100 TO 109. SEE
YOUR HEALTH CARE PROVIDER WITHIN THE NEXT MONTH TO
HAVE YOUR BLOOD PRESSURE RECHECKED AND MANAGED.
4. SYSTOLIC BP 140 TO 159 OR DIASTOLIC BP 90 TO 99. SEE YOUR
HEALTH CARE PROVIDER WITHIN THE NEXT TWO MONTHS TO
HAVE YOUR BLOOD PRESSURE RECHECKED AND MANAGED.
5. SYSTOLIC BP 120 TO 139 OR DIASTOLIC BP 80 TO 89. FIND OUT
FROM YOUR HEALTH CARE PROVIDER IF LIFESTYLE CHANGES OR
TREATMENTS ARE NEEDED.
6. SYSTOLIC BP <120 AND DIASTOLIC BP <80. YOUR BLOOD
PRESSURE IS WITHIN NORMAL LIMITS. TALK TO YOUR HEALTH
CARE PROVIDER ABOUT HEALTHY LIFESTYLE CHOICES THAT YOU
CAN TAKE TO PREVENT HIGH BLOOD PRESSURE.
[GO TO QUESTION D12]
D11f. DOCUMENTATION OF REFERRAL
1. OFFERED, ACCEPTED, PROVIDED
2. OFFERED, ACCEPTED, CASE REFERRED TO CALL CENTER FOR
ASSISTANCE
3. OFFERED, DECLINED
4. NOT OFFERED

D12. Do you use a medication or inhaler for a lung condition?
Yes......................... 1
No .......................... 2 [GO TO QUESTION D13]
DON’T KNOW........ 3 [GO TO QUESTION D13]
REFUSED.............. 4 [GO TO QUESTION D13]
D12a. What medication(s) do you take?
[FREE TEXT FIELD]
D12b. When did you last take this medication? [PROGRAMMER NOTE:
REPEAT FOR EACH MEDICATION GIVEN IN D12a]
[FREE TEXT FIELD]

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[INTERVIEWER: THE FOLLOWING QUESTIONS ARE EXCLUSION
CRITERIA FOR THE PULMONARY FUNCTION TESTING. IF THE
RESPONDENT ANSWERS “YES”, “DON’T KNOW” OR “REFUSED” TO ANY
OF THE FOLLOWING QUESTIONS (D12 – D17), DO NOT ADMINISTER
THE PULMONARY FUNCTION TEST]. IF HEART RATE IS > 120 AS
INDICATED IN ANY OF D11a.1 - D11c.1 DO NOT ADMINISTER THE
PULMONARY FUNCTION TEST.
RESULTS FROM D11a.1: [PIPE IN RESULT]
RESULTS FROM D11b.1: [PIPE IN RESULT]
RESULTS FROM D11c.1: [PIPE IN RESULT]

D13. In the past three months, have you had any surgery to your chest or
abdomen?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
D14. In the past three months, have you had a heart attack or stroke?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
D15. In the past three months, have you had a detached retina or eye surgery?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
D16. In the past three months, have you been hospitalized for any other heart
problem?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
D17. [INTERVIEWER: ONLY ASK IF PARTICIPANT IS FEMALE] Are you
pregnant?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
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REFUSED.............. 9
D18. Are you currently taking medication for tuberculosis?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
[INTERVIEWER: IF ANY OF D13 – D18= YES, DON’T KNOW, OR REFUSED
DO NOT COMPLETE THE PULMONARY FUNCTION TESTING]
D19. WAS PULMONARY FUNCTION TESTING COMPLETED?
YES ........................1
NO ..........................2 PLEASE PROVIDE A REASON: [DROP DOWN BOX
WITH SPECIFIC REASONS AND OTHER]
D20. How many hours has it been since you last ate food or drank anything
besides water?
| __ | __ | [# HOURS]
D21. WERE BLOOD SAMPLES COLLECTED?
YES ... 1 [GO TO D22]
NO..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD]
D21a. WAS AN ORAGENE SALIVA COLLECTION KIT PROVIDED?
YES ........................1
NO ..........................2 [GO TO QUESTION D30]
D21a.1. INDICATE TIME OF SALIVA COLLECTION.
__/__/ : __/__/
AM …….1 [GO TO QUESTION D30]
PM ……..2 [GO TO QUESTION D30]
D22. INDICATE TIME OF BLOOD COLLECTION.
__/__/ : __/__/
AM...........…….1
PM..........……..2
D23. WHICH ARM WAS BLOOD COLLECTED FROM?
LEFT ARM ........... 1
RIGHT ARM ......... 2
D24. WHICH VEIN WAS USED FOR COLLECTION?
CEPHALIC ......................1
MEDIAN CUBITAL ..........2
BASILIC ..........................3
OTHER............................4
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D25. INDICATE THE NUMBER OF COLLECTION ATTEMPTS (STICKS).
____ ATTEMPT(S)

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D26. DID YOU COLLECT THE FOLLOWING TUBES…
D26a. TUBE 1, 10 ML RED TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26b. TUBE 2, 10 ML RED TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26c. TUBE 3, 10 ML PURPLE TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26d. TUBE 4, 6 ML YELLOW TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26e. TUBE 5, 6 ML ROYAL BLUE TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26f. TUBE 6, 2 ML PURPLE TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26g. TUBE 7, 6 ML PURPLE TOP?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]
D26h. TUBE 8, PAXGENE RNA TUBE?
YES ...... 1
NO........ 2 REASON? [FREE TEXT FIELD]

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QUALITY CONTROL TUBES [PROGRAMMER NOTE: ONLY SHOW THE
FOLLOWING TUBES FOR THE QC PARTICIPANTS]
D26i. QCTUBE 1, RED TOP?
YES...... 1
NO ....... 2 REASON? [FREE TEXT FIELD]
D26j. QCTUBE 2, PURPLE TOP?
YES...... 1
NO ....... 2 REASON? [FREE TEXT FIELD]
D26k. QCTUBE 3, YELLOW TOP?
YES...... 1
NO ....... 2 REASON? [FREE TEXT FIELD]
D26l. QCTUBE 4, BLUE TUBE?
YES...... 1
NO ....... 2 REASON? [FREE TEXT FIELD]
D27. WAS SERUM SEPARATED FROM THE RED TOP TUBES (TUBES 1
AND 2)?
YES ... 1
NO ..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D2]
D28. [PROGRAMMER NOTE: ONLY SHOW FOR ACTIVE SUBCOHORT
NOT BIOMEDICAL SURVEILLANCE SUBCOHORT] WAS PLASMA
SEPARATED FROM THE YELLOW TOP TUBE (TUBE 4)?
YES ... 1
NO ..... 2 BIOMEDICAL SURVEILLANCE SUBCOHORT
NO ..... 3 PLEASE PROVIDE A REASON: [FREE TEXT FIELD]

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D29. [PROGRAMMER NOTE: ONLY SHOW IF D27 OR D28 = 1]
RECORD TIME THAT SPECIMENS WERE CENTRIFUGED.
__/__/ : __/__/
AM ....... 1
PM ....... 2

D30. WAS A HAIR SAMPLE COLLECTED?
YES ... 1
NO ..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D31]
D30a. WERE THE PROXIMAL AND DISTAL ENDS OF THE HAIR
DESIGNATED?
YES..............1
NO ...............2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD]
D31. WERE TOENAIL SAMPLES COLLECTED?
YES ... 1
NO ..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D32]

D32. [PROGRAMMER NOTE: DUST COLLECTION WILL NOT BE
COLLECTED IF HOME VISIT IS AT AN ALTERNATE LOCATION. IF A3b,
B2b, B4b, OR B6b = 2 DO NOT SHOW QUESTION D32] WAS A DUST
SAMPLE COLLECTED?
YES ... 1
NO ..... 2 PLEASE PROVIDE A REASON: [FREE TEXT FIELD] [GO TO
QUESTION D33]
D32a. INDICATE LOCATION(S) FROM WHICH DUST WAS
COLLECTED:
[SELECT ALL FOR COLLECTION LOCATIONS]

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D33. WAS A NON-ACUTE MENTAL HEALTH REFERRAL REQUESTED OR
OFFERED?
YES, REQUESTED BY PARTICIPANT .......................1
YES, OFFERED BASED ON HVA OBSERVATION ....2
NO................................................................................3 [GO TO D34]
D33a. REASON FOR REFERRAL
[FREE TEST FIELD]
D33b. DOCUMENTATION OF REFERRAL
1. OFFERED, ACCEPTED, PROVIDED
2. OFFER REQUESTED, PROVIDED
3. OFFERED, DECLINED
4. NO REFERRAL PROVIDED

D34. RECORD GPS COORDINATES
______________________
NOT OBTAINED............... 2 REASON _______________
D34a. RECORD LANDMARKS FOR HOME
______________________
NOT OBTAINED .... 2 REASON _______________

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Part 5: Home Visit Questionnaire
(Estimated Burden: Shortest Path = 31
minutes; Longest Path = 66 minutes)

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SECTION E: Clean-up Related Tasks and Exposures During Clean-up

[CAPI: CONTROLS GO TO SECTION F]
[INTERVIEWER: FOR EACH SPECIFIC JOB MARKED YES, CAPI WILL
TAKE YOU THROUGH A SERIES OF EXPOSURE QUESTIONS FOR THAT
PARTICULAR JOB. IT WILL REPEAT THE SERIES FOR EACH JOB
MARKED YES]
I would like to begin our interview by asking you some questions about your [FILL
IN JOB] job that we did not ask you about on the telephone.
$$ [BEGIN MATRIX FOR EXPOSURE BY JOB]
E1. When you [FILL IN JOB], how often do/did you smell or breathe in exhaust
fumes from the engines of ATVs, UTVs, trucks, boats, generators or other mobile
equipment? Was it…
>40 hr/wk
10-39 hr/wk
1-9 hr/wk
<1 hr/wk
Never ................... 5
DON’T KNOW...... 8
REFUSED............ 9
E2. When you [FILL IN JOB], do/did you usually smell an odor for at least 10
minutes a day from oil on the beach, in the water or on animals or equipment,
from dispersants or from cleaning chemicals?
Yes......................... 1
No .......................... 2 [GO TO QUESTION E3]
DON’T KNOW........ 8 [GO TO QUESTION E3]
REFUSED.............. 9 [GO TO QUESTION E3]
E2a. Was the odor…
E2a1. Sweet
E2a2. Sour
E2a3. Pleasant
E2a4. Obnoxious
E2a5. Irritating to the eyes
E2a6. Irritating to the nose

YES NO
1
2
1
2
1
2
1
2
1
2
1
2

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DK
8
8
8
8
8
8

RE
9
9
9
9
9
9

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E3. If you usually wore gloves, did you wear a second glove inside the outside
glove?
DID NOT WEAR GLOVES
YES
NO
DK
REF
E4. How often when you [FILL IN JOB] did your part of you clothing or any of
your body become wet with a chemical?
<1day 1-4 d/mo 1-5 d/wk almost every day
Head area
Forearms
Upper arms
Front of chest
Back
Upper legs
Lower legs
E5. How often did your shoes become contaminated with oil or an oily residue,
such as weathered oil or tar or with a chemical due to a tear in your booties or
yellow chicken feet?
<1 day/month…….1
1-4 days/month…..2
1-5 days/week…..3
Almost every day….4

$$[END MATRIX FOR EXPOSURE BY JOB]

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SECTION F: Health
Now I will ask you some questions about your health beginning with any
medications you may be taking.
F1. Are you currently using any over-the-counter or prescription medications for
any reason?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F2]
DON’T KNOW........ 8 [GO TO QUESTION F2]
REFUSED.............. 9 [GO TO QUESTION F2]
F1a. If you have not already done so, please collect your medications so
that I can record what you are taking.
[INTERVIEWER: RECORD MEDICINE NAME AND DOSAGE DIRECTLY
FROM THE MEDICINE CONTAINER]
[MEDICATION COLLECTION TABLE WITH MEDICATION, DOSE, AND
FREQUENCY]
F1b. Are there any other medications that you are taking?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F2]
DON’T KNOW ........ 8 [GO TO QUESTION F2]
REFUSED .............. 9 [GO TO QUESTION F2]
F1b.1 [INTERVIEWER: RECORD REPORTED MEDICINE NAME
AND DOSAGE; MEDICATION COLLECTION TABLE WITH
MEDICATION, DOSE, AND FREQUENCY]
The following questions are about colds and the flu.
[PROGRAMMER NOTE: FOR QUESTIONS F2 – F7b, NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW
≤ OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF DATE OF INTERVIEW
IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “two years”;
IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “three years”]

During the past [YEAR FILL], have you had any of the following conditions?
F2. …Cold(s)
Yes......................... 1
No .......................... 2 [GO TO QUESTION F3]
DON’T KNOW........ 8 [GO TO QUESTION F3]
REFUSED.............. 9 [GO TO QUESTION F3]
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F2a. How many colds in the past [YEAR FILL]?
I_I_I_I Episodes
F3. …Flu or Influenza
Yes......................... 1
No .......................... 2 [GO TO QUESTION F4]
DON’T KNOW........ 8 [GO TO QUESTION F4]
REFUSED.............. 9 [GO TO QUESTION F4]
F3a. How many episodes in the past [YEAR FILL]?
I_I_I_I Episodes
F4. In the past [YEAR FILL], have you had a flu shot?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
F5. In the past [YEAR FILL], other than due to a cold or the flu, have you had a
stuffy, itchy or runny nose?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F6]
DON’T KNOW........ 8 [GO TO QUESTION F6]
REFUSED.............. 9 [GO TO QUESTION F6]
F5a. How many episodes in the past [YEAR FILL]?
I_I_I_I Episodes
F6. In the past [YEAR FILL], have you had sinusitis or sinus problems?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F7]
DON’T KNOW........ 8 [GO TO QUESTION F7]
REFUSED.............. 9 [GO TO QUESTION F7]
F6a. How many episodes in the past [YEAR FILL]?
I_I_I_I Episodes
F7. Have you ever had cold sores or fever blisters on your lips?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F8]
DON’T KNOW........ 8 [GO TO QUESTION F8]
REFUSED.............. 9 [GO TO QUESTION F8]
F7a. In the past [YEAR FILL], have you had at least one episode of cold
sores?

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Yes......................... 1
No .......................... 2 [GO TO QUESTION F8]
DON’T KNOW ........ 8 [GO TO QUESTION F8]
REFUSED .............. 9 [GO TO QUESTION F8]
F7b. Have your cold sores been worse or more frequent in the past [YEAR
FILL]?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
Respiratory Symptoms
The next set of questions is about respiratory symptoms. These questions
pertain mainly to your chest.
F8. Do you usually have a cough? [INTERVIEWER PROBE: Count a cough with
first smoke or on first going out-of-doors. Exclude clearing of throat.]
Yes....................... 1
No ........................ 2 [GO TO QUESTION F13]
DON’T KNOW...... 8 [GO TO QUESTION F13]
REFUSED............ 9 [GO TO QUESTION F13]
F9. Do you usually cough as much as 4 to 6 times a day, 4 or more days out of
the week?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F10. Do you usually cough at all on getting up, or first thing in the morning?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F11. Do you usually cough at all during the rest of the day or at night?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
[IF YES TO ANY OF THE ABOVE (F8 – F11), ANSWER THE FOLLOWING
QUESTION F12. IF NO TO ALL GO TO F13.]
F12. For how long have you had this cough?
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|_|_|_I Units
Days....................... 1
Weeks.................... 2
Months ................... 3
Years ..................... 4
DON’T KNOW........ 88 [GO TO QUESTION F13]
REFUSED.............. 99 [GO TO QUESTION F13]
[IF F12 < # OF UNITS SINCE APRIL 20, GO TO QUESTION F13]
[PROGRAMMER NOTE: FOR QUESTIONS F12a ,F16a, F21a, AND
F27b, NUMBER OF YEARS WILL CHANGE BASED ON DATE OF
INTERVIEW. IF DATE OF INTERVIEW ≤ OCTOBER 1, 2011 USE “two
years” FOR [YEAR FILL]; IF DATE OF INTERVIEW IS BETWEEN
OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “three years”; IF
DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “four years”]

F12a. Thinking about [YEAR FILL] ago, how has this condition been in the
past thirty days?
Better ..................... 1
Worse..................... 2
No Change ............. 3
Resolved ................ 4
DON’T KNOW ........ 8
REFUSED .............. 9
F13. Do you usually bring up phlegm from your chest? [INTERVIEWER PROBE:
Count phlegm with the first smoke or on first going out-of-doors. Exclude phlegm
from the nose. Count swallowed or spit phlegm.]
Yes....................... 1
No ........................ 2 [GO TO QUESTION F14]
DON’T KNOW...... 8 [GO TO QUESTION F14]
REFUSED............ 9 [GO TO QUESTION F14]
F13a. Do you usually bring up phlegm like this as much as twice a day, 4
or more days out of the week?
Yes ............ 1
No ............. 2
DON’T KNOW 8
REFUSED . 9
F14. Do you usually bring up phlegm at all on getting up or first thing in the
morning?
Yes....................... 1
No ........................ 2
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DON’T KNOW...... 8
REFUSED............ 9
F15. Do you usually bring up phlegm at all during the rest of the day or at night?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
[IF YES TO F13 - F15, ANSWER THE FOLLOWING QUESTION F16. IF NO
TO ALL GO TO F17.]
F16. For how long have you had trouble with phlegm?
|_|_|_I Units
Days....................... 1
Weeks.................... 2
Months ................... 3
Years ..................... 4
DON’T KNOW........ 88 [GO TO QUESTION F17]
REFUSED.............. 99 [GO TO QUESTION F17]
[IF F16< # OF UNITS SINCE APRIL 20, GO TO QUESTION F17]
F16a. Thinking about [YEAR FILL] ago, how has this condition been in the
past thirty days?
Better ..................... 1
Worse..................... 2
No Change ............. 3
Resolved ................ 4
DON’T KNOW ........ 8
REFUSED .............. 9
F17. Have you had periods or episodes of (increased*) cough and phlegm lasting
at least three weeks or more each year? [*FOR INDIVIDUALS WHO USUALLY
HAVE COUGH AND / OR PHLEGM]
Yes......................... 1
No .......................... 2 [GO TO QUESTION F18]
DON’T KNOW........ 8 [GO TO QUESTION F18]
REFUSED.............. 9 [GO TO QUESTION F18]
F17a. For how long have you had at least on such episode per year?
I_I_I [# OF YEARS]
DON’T KNOW ........ 8
REFUSED .............. 9

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F18. Does your chest ever sound wheezy or whistling when you have a cold?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F19. Does your chest ever sound wheezy or whistling occasionally apart from
colds?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F20. Does your chest sound wheezy or whistling most days or nights?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
[IF YES TO F18 – F20, ANSWER THE FOLLOWING QUESTIONS F21. IF
NO TO ALL GO TO F22.]
F21 For how long has this been present?
|_|_|_I Units
Days....................... 1
Weeks.................... 2
Months ................... 3
Years ..................... 4
DON’T KNOW........ 88
REFUSED.............. 99
[IF F21 < # OF UNITS SINCE APRIL 20, GO TO QUESTION F22]
F21a. Thinking about [YEAR FILL] ago, how has this condition been in the
past thirty days?
Better ..................... 1
Worse..................... 2
No Change ............. 3
Resolved ................ 4
DON’T KNOW ........ 8
REFUSED .............. 9
F22. Have you ever had an attack of wheezing that has made you feel short of
breath?

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Yes....................... 1
No ........................ 2 [GO TO QUESTION F23]
DON’T KNOW...... 8 [GO TO QUESTION F23]
REFUSED............ 9 [GO TO QUESTION F23]
F22a. How old were you when you had your first such attack?
__ | __ Number of years
DON’T KNOW ................... 88
REFUSED ......................... 99
F22b. Have you had 2 or more such episodes?
Yes.................................... 1
No ..................................... 2 [GO TO QUESTION F23]
DON’T KNOW ................... 8
REFUSED ......................... 9 [GO TO QUESTION F22d]
F22c. Have you ever required medicine or treatment for the(se) attack(s)?
Yes.................................... 1
No ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9
[PROGRAMMER NOTE: FOR QUESTION F22d NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL];
IF DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “three years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “four years”]

F22d. Before [YEAR FILL] ago, how many such attacks did you have in a
typical year?
__ | __ Number of attacks
NO SUCH ATTACKS ........ 00
DON’T KNOW ................... 88
REFUSED ......................... 99
[PROGRAMMER NOTE: FOR QUESTION F22e NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL];
IF DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “three years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “four years”]

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F22e. In the past [YEAR FILL], how many such attacks have you had?
__ | __ Number of attacks
NO SUCH ATTACKS ....... 00
DON’T KNOW ................... 88
REFUSED ......................... 99
F23. Do you have shortness of breath when hurrying on a level surface or
walking up a slight hill?
Yes....................... 1
No ........................ 2 [GO TO QUESTION F28]
DON’T KNOW...... 8 [GO TO QUESTION F28]
REFUSED............ 9 [GO TO QUESTION F28]
F24. Do you have to walk slower than people of your age on a level surface
because of breathlessness?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F25. Do you ever have to stop for breath when walking at your own pace on a
level surface?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F26. Do you ever have to stop for breath after walking about 100 yards or after a
few minutes on a level surface?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F27. Are you too breathless to leave the house or do you get breathless when
dressing or undressing?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8 [GO TO QUESTION F28]
REFUSED............ 9 [GO TO QUESTION F28]
F27a. For how long have you had trouble with breathlessness?
|_|_|_I Units
Days ....................... 1
Weeks .................... 2
Months ................... 3

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Years...................... 4
DON’T KNOW ........ 88
REFUSED .............. 99
[IF F27a < # OF UNITS SINCE APRIL 20, GO TO QUESTION F28]
F27b. Thinking about [YEAR FILL] ago, how has this condition been in the
past thirty days?
Better ..................... 1
Worse..................... 2
No Change ............. 3
Resolved ................ 4
DON’T KNOW ........ 8
REFUSED .............. 9
F28. If you get a cold, does it usually go to your chest? Usually means more than
half the time.
Yes....................... 1
No ........................ 2
Don’t get colds ..... 3
DON’T KNOW...... 8
REFUSED............ 9
[PROGRAMMER NOTE: FOR QUESTION F29, F31, AND F32,
NUMBER OF YEARS WILL CHANGE BASED ON DATE OF
INTERVIEW. IF DATE OF INTERVIEW ≤ OCTOBER 1, 2011 USE “two
years” FOR [YEAR FILL]; IF DATE OF INTERVIEW IS BETWEEN
OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “three years”; IF
DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “four years”]
F29. During the past [YEAR FILL], have you had any chest illnesses that kept
you off work, indoors at home, or in bed?
Yes....................... 1
No ........................ 2 [GO TO QUESTION F33]
DON’T KNOW...... 8 [GO TO QUESTION F33]
REFUSED............ 9 [GO TO QUESTION F33]
F30. Did you produce phlegm with any of these chest illnesses?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F31. Before [YEAR FILL] ago, how many such illnesses where you had
increased phlegm did you have that lasted a week or more in a typical year?
__ | __ Number of illnesses
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NO SUCH ILLNESSES..... 00
DON’T KNOW................... 88
REFUSED......................... 99
F32. During the past [YEAR FILL], how many such illnesses where you had
increased phlegm have you had that lasted a week or more?
__ | __ Number of illnesses
NO SUCH ILLNESSES..... 00
DON’T KNOW................... 88
REFUSED......................... 99
F33. Did you have any lung trouble before the age of 16?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
Have you ever had…
F34. …attacks of bronchitis?
Yes....................... 1
No ........................ 2 [GO TO QUESTION F35]
DON’T KNOW...... 8 [GO TO QUESTION F35]
REFUSED............ 9 [GO TO QUESTION F35]
F34a. Was it confirmed by a doctor?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F34b. At what age was your first attack?
__ | __ Age in years
DON’T KNOW ........ 88
REFUSED .............. 99
[PROGRAMMER NOTE: FOR QUESTION F34c, NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL];
IF DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “three years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “four years”]

F34c. Did you see a doctor for this condition [YEAR FILL] ago?
Yes......................... 1
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No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
[PROGRAMMER NOTE: FOR QUESTION F34d, NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF
DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “two years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “three years”]

F34d. Have you seen a doctor for this condition in the past [YEAR FILL]?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F35. Have you ever had pneumonia?
Yes....................... 1
No ........................ 2 [GO TO QUESTION F36]
DON’T KNOW...... 8 [GO TO QUESTION F36]
REFUSED............ 9 [GO TO QUESTION F36]
F35a. Was it confirmed by a doctor?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F35b. At what age did you first have it?
__ | __ Age in years
DON’T KNOW ........ 88
REFUSED .............. 99

[PROGRAMMER NOTE: FOR QUESTION F35c NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL];
IF DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “three years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “four years”]

F35c. Did you see a doctor for this condition [YEAR FILL] ago?

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Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
[PROGRAMMER NOTE: FOR QUESTION F34d, NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF
INTERVIEW ≤ OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF
DATE OF INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND
OCTOBER 1, 2012 USE “two years”; IF DATE OF INTERVIEW ≥
OCTOBER 2, 2012 USE “three years”]

F35d. Did you see a doctor for this condition in the past [YEAR FILL]?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F36. Have you ever had hay fever?
Yes....................... 1
No ........................ 2 [GO TO QUESTION F37]
DON’T KNOW...... 8 [GO TO QUESTION F37]
REFUSED............ 9 [GO TO QUESTION F37]
F36a. Was it confirmed by a doctor?
Yes......................... 1
No .......................... 2
DON’T KNOW ........ 8
REFUSED .............. 9
F36b. At what age did it start?
__ | __ Age in years
DON’T KNOW ........ 88
REFUSED .............. 99
F37. Have you ever had any other chest illnesses?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F38]
DON’T KNOW........ 8 [GO TO QUESTION F38]
REFUSED.............. 9 [GO TO QUESTION F38]
F37a. If yes, please specify [FREE TEXT FIELD]
F37b. When was it diagnosed? [MONTH AND YEAR ONLY]
__ __ / __ __ __ __ [MM/YYYY]
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DON’T KNOW ........ 88/8888
REFUSED .............. 99/9999
F38. Have you ever had any chest illnesses that required surgery?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F39]
DON’T KNOW........ 8 [GO TO QUESTION F39]
REFUSED.............. 9 [GO TO QUESTION F39]
F38a. If yes, please specify [FREE TEXT FIELD]
F38b. When was it diagnosed? [MONTH AND YEAR ONLY]
__ __ / __ __ __ __ [MM/YYYY]
DON’T KNOW ........ 88/8888
REFUSED .............. 99/9999
F39. Have you ever had any chest injuries?
Yes......................... 1
No .......................... 2 [GO TO QUESTION F40]
DON’T KNOW........ 8 [GO TO QUESTION F40]
REFUSED.............. 9 [GO TO QUESTION F40]
F39a. If yes, please specify [FREE TEXT FIELD]
F39b. When did the injury occur? [MONTH AND YEAR ONLY]
__ __ / __ __ __ __ [MM/YYYY]
DON’T KNOW ........ 88/8888
REFUSED .............. 99/9999
During the past 7 days, have you had…
F40. A stuffy, itchy, or runny nose?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F41. Watery, itchy eyes?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F42. A cold?
Yes....................... 1
No ........................ 2

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DON’T KNOW...... 8
REFUSED............ 9
F43. Sinusitis or sinus problems?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F44. Flu?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F45. Pneumonia?
Yes....................... 1
No ........................ 2
DON’T KNOW...... 8
REFUSED............ 9
F46. Fever?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
F47. During the past thirty days, have you had any health problems that we did
not discuss today?
Yes............................................... 1
No ................................................ 2 [GO TO SECTION G]
DON’T KNOW..............................8 [GO TO SECTION G]
REFUSED.................................... 9 [GO TO SECTION G]
F47a. What was it?
F47a.1. Type 1: [FREE TEXT FIELD]
F47a.1a. Did you have any others?
Yes.................................... 1
No ..................................... 2 [GO TO SECTION G]
DON’T KNOW ................... 8 [GO TO SECTION G]
REFUSED ......................... 9 [GO TO SECTION G]
F47a.2. Type 2: [FREE TEXT FIELD]
F47a.2a. Did you have any others?
Yes.................................... 1
No ..................................... 2 [GO TO SECTION G]

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DON’T KNOW ................... 8 [GO TO SECTION G]
REFUSED ......................... 9 [GO TO SECTION G]
F47a.3. Type 2: [FREE TEXT FIELD]
F47a.3a. Did you have any others?
Yes.................................... 1
No ..................................... 2 [GO TO SECTION G]
DON’T KNOW ................... 8 [GO TO SECTION G]
REFUSED ......................... 9 [GO TO SECTION G]
F47a.4. Type 2: [FREE TEXT FIELD]
F47a.4a. Did you have any others?
Yes.................................... 1
No ..................................... 2 [GO TO SECTION G]
DON’T KNOW ................... 8 [GO TO SECTION G]
REFUSED ......................... 9 [GO TO SECTION G]
F47a.5. Type 2: [FREE TEXT FIELD]
Yes.................................... 1
No ..................................... 2
DON’T KNOW ................... 8
REFUSED ......................... 9

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SECTION G: Access to Healthcare
Okay. Thank you. Now I will ask you about how you meet your health care
needs.
G1. Do you have any kind of health care coverage, including health insurance,
prepaid plans such as HMOs, or government plans such as Medicaid, TRICARE,
and Veterans Benefits, or a state health care plan?
Yes.................................... 1
No ..................................... 2 [GO TO G3]
DON’T KNOW................... 8 [GO TO G3]
REFUSED......................... 9 [GO TO G3]
G2. Does your health care plan include mental health coverage?
Yes.................................... 1
No ..................................... 2
DON’T KNOW................... 8
REFUSED......................... 9
G3. Do you have one person you think of as your personal doctor or health care
provider?
Yes, only one .................... 1 [GO TO QUESTION G4]
More than one................... 2 [GO TO QUESTION G4]
No ..................................... 3 [GO TO QUESTION G4]
DON’T KNOW................... 8
REFUSED......................... 9
G3a. Is there more than one, or is there no person who you think of as
your personal doctor or health care provider?
More than one ..............................1
No person who I think of as my personal doctor
or health care provider ................2
DON’T KNOW ..............................8
REFUSED ....................................9
G4. Do you know of a clinic or health care provider where you can go to get
medical care?
Yes.................................... 1
No ..................................... 2
DON’T KNOW................... 8
REFUSED......................... 9

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SECTION H: Family Medical History
These next questions are about your family’s medical history. For these
questions, please think about your blood relatives only. Do not include people
who are related to you by marriage or adoption. If you are adopted please
answer only for biological relatives that you know about.
Siblings
H1. How many brothers do you have, including those who are deceased?
__/__/ brothers
DON’T KNOW........ 8
REFUSED.............. 9
H2. How many sisters do you have, including those who are deceased?
__/__/ sisters
DON’T KNOW........ 8
REFUSED.............. 9

Respiratory Symptoms / Diseases – Family History
The next group of questions is about your family’s history of respiratory
symptoms and diseases.
H3. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had asthma?
Yes.............................1
No ..............................2 [GO TO QUESTION H5]
DON’T KNOW............8 [GO TO QUESTION H5]
REFUSED..................9 [GO TO QUESTION H5]
H4. Please tell me which relative(s).
YES NO
DK
H4a. Mother
1
2
8
H4b. Father
1
2
8
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H4c]
H4c. Sister
1
2
8
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H4d]
H4d. Brother
1
2
8

RE
9
9
9
9

H5. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had a chronic lung condition such as emphysema or chronic bronchitis?
Yes.............................1

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No ..............................2 [GO TO QUESTION H7]
DON’T KNOW............8 [GO TO QUESTION H7]
REFUSED..................9 [GO TO QUESTION H7]
H6. Please tell me which relative(s) were diagnosed with a chronic lung
condition.
YES NO
DK
RE
H6a. Mother
1
2
8
9
H6b. Father
1
2
8
9
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H6c]
H6c. Sister
1
2
8
9
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H6d]
H6d. Brother
1
2
8
9
Cardiovascular Disease – Family History
These next questions are about your family history of heart attacks and
cardiovascular disease.
H7. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had a heart attack or myocardial infarction?
Yes.............................1
No ..............................2 [GO TO QUESTION H9]
DON’T KNOW............8 [GO TO QUESTION H9]
REFUSED..................9 [GO TO QUESTION H9]
H8. Please tell me which blood relative(s) had a heart attack or myocardial
infarction?
YES NO
DK
RE
H8a. Mother
1
2
8
9
H8b. Father
1
2
8
9
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H8c]
H8c. Sister
1
2
8
9
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H8d]
H8d. Brother
1
2
8
9
H9. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Has your father or mother [or siblings] ever had heart procedures, for
example, coronary bypass surgery or balloon angioplasty?
Yes.............................1
No ..............................2 [GO TO QUESTION H11]
DON’T KNOW............8 [GO TO QUESTION H11]
REFUSED..................9 [GO TO QUESTION H11]
H10. Please tell me which relative(s) had a heart procedure.
YES NO
DK

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RE

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H10a. Mother
1
2
8
H10b. Father
1
2
8
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H10c]
H10c. Sister
1
2
8
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H10d]
H10d. Brother
1
2
8

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9
9
9
9

H11. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had a stroke, cerebral hemorrhage, or brain attack?
Yes.............................1
No ..............................2 [GO TO QUESTION H13]
DON’T KNOW............8 [GO TO QUESTION H13]
REFUSED..................9 [GO TO QUESTION H13]
H12. Please tell me which relative(s) had a stroke, cerebral hemorrhage, or brain
attack.
YES NO
DK
RE
H12a. Mother
1
2
8
9
H12b. Father
1
2
8
9
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H12c]
H12c. Sister
1
2
8
9
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H12d]
H12d. Brother
1
2
8
9
H13. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had hypertension or high blood pressure?
Yes.............................1
No ..............................2 [GO TO QUESTION H15]
DON’T KNOW............8 [GO TO QUESTION H15]
REFUSED..................9 [GO TO QUESTION H15]
H14. Please tell me which relative(s) had hypertension or high blood pressure.
YES NO
DK
RE
H14a. Mother
1
2
8
9
H14b. Father
1
2
8
9
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H14c]
H14c. Sister
1
2
8
9
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H14d]
H14d. Brother
1
2
8
9
Diabetes – Family History

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H15. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had diabetes or high blood sugar?
Yes.............................1
No ..............................2 [GO TO QUESTION H17]
DON’T KNOW............8 [GO TO QUESTION H17]
REFUSED..................9 [GO TO QUESTION H17]
H16. Please tell me which relative(s) had diabetes or high blood sugar.
YES NO
DK
H16a. Mother
1
2
8
H16b.. Father
1
2
8
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H16c]
H16c. Sister
1
2
8
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H16d]
H16d. Brother
1
2
8

RE
9
9
9
9

Cancer – Family History
These next questions are about your family history of cancer.
H17. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had cancer?
Yes.............................1
No ..............................2 [GO TO QUESTION H19]
DON’T KNOW............8 [GO TO QUESTION H19]
REFUSED..................9 [GO TO QUESTION H19]
H18. Please tell me which relative(s) had cancer.
YES NO
H18a. Mother
1
2
H18b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H18c]
H18c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H18d]
H18d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

H18e. What type of cancer did each of them have?
[INTERVIEWER: RECORD UP TO SIX TYPES OF CANCER]
H18e.1-6. Type: [SELECT FROM CANCER OPTIONS]
H18e.1-6.a. OTHER [SPECIFY] ____________________
Neurological Disease – Family History
These next questions are about your family history of nerve diseases.

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H19. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had epilepsy?
Yes.............................1
No ..............................2 [GO TO QUESTION H21]
DON’T KNOW............8 [GO TO QUESTION H21]
REFUSED..................9 [GO TO QUESTION H21]
H20. Please tell me which relative(s) had epilepsy.
YES NO
H20a. Mother
1
2
H20b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H20c]
H20c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H20d]
H20d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

H21. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had amyotrophic lateral sclerosis, also known as ALS, motor neuron disease,
and Lou Gehrig’s disease?
Yes.............................1
No ..............................2 [GO TO QUESTION H23]
DON’T KNOW............8 [GO TO QUESTION H23]
REFUSED..................9 [GO TO QUESTION H23]
H22. Please tell me which relative(s) had ALS.
YES NO
H22a. Mother
1
2
H22b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H22c]
H22c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H22d]
H22d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

H23. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had Parkinson’s disease?
Yes.............................1
No ..............................2 [GO TO QUESTION H25]
DON’T KNOW............8 [GO TO QUESTION H25]
REFUSED..................9 [GO TO QUESTION H25]
H24. Please tell me which relative(s) had Parkinson’s disease.
YES NO
H24a. Mother
1
2

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DK
8

RE
9

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H24b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H24c]
H24c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H24d]
H24d. Brother
1
2

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8

9

8

9

8

9

H25. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had Alzheimer’s disease?
Yes.............................1
No ..............................2 [GO TO QUESTION H27]
DON’T KNOW............8 [GO TO QUESTION H27]
REFUSED..................9 [GO TO QUESTION H27]
H26. Please tell me which relative(s) had Alzheimer’s disease.
YES NO
H26a. Mother
1
2
H26b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H26c]
H26c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H26d]
H26d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

Autoimmune Disease – Family History
These next questions are about your family history of autoimmune diseases.
H27. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had lupus?
Yes.............................1
No ..............................2 [GO TO QUESTION H29]
DON’T KNOW............8 [GO TO QUESTION H29]
REFUSED..................9 [GO TO QUESTION H29]
H28. Please tell me which relative(s) have had lupus.
YES NO
H28a. Mother
1
2
H28b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H28c]
H28c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H28d]
H28d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

H29. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had rheumatoid arthritis?

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Yes.............................1
No ..............................2 [GO TO QUESTION H31]
DON’T KNOW............8 [GO TO QUESTION H31]
REFUSED..................9 [GO TO QUESTION H31]
H30. Please tell me which relative(s) have had rheumatoid arthritis.
YES NO
H30a. Mother
1
2
H30b. Father
1
2
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H30c]
H30c. Sister
1
2
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H30d]
H30d. Brother
1
2

DK
8
8

RE
9
9

8

9

8

9

H31. [PROGRAMMER NOTE: IF H1 AND H2 BOTH = 0, DO NOT SHOW “or
siblings”] Was your father or mother [or siblings] ever told by a doctor that they
had Grave’s disease or other thyroid disease?
Yes.............................1
No ..............................2 [GO TO SECTION I]
DON’T KNOW............8 [GO TO SECTION I]
REFUSED..................9 [GO TO SECTION I]
H32. Please tell me which relative(s) have had Grave’s disease or other thyroid
disease.
YES NO
DK
RE
H32a. Mother
1
2
8
9
H32b. Father
1
2
8
9
[PROGRAMMER NOTE: IF H2 = 0 DO NOT SHOW H32c]
H32c. Sister
1
2
8
9
[PROGRAMMER NOTE: IF H1 = 0 DO NOT SHOW H32d]
H32d. Brother
1
2
8
9

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SECTION I: Mental Health
Now I am going to ask you some questions about your mood. When answering
these questions, please think about how many days each of the following has
occurred in the past two weeks.
Anxiety
I1. Over the last 2 weeks, how many days have you been nervous, anxious, or
on edge?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I2. Over the last 2 weeks, how many days have you not been able to stop or
control worrying?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I3. Over the last 2 weeks, how many days have you worried too much about
different things?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I4. Over the last 2 weeks, how many days have you had trouble relaxing?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I5. Over the last 2 weeks, how many days have you been so restless that it was
hard to sit still?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I6. Over the last 2 weeks, how many days have you been easily annoyed or
irritable?
01-14 days ................... _ _
None ............................. 00

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DON’T KNOW............... 88
REFUSED..................... 99
I7. Over the last 2 weeks, how many days have you felt afraid as if something
awful might happen?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
Depression
The next set of questions is about depression.
I8. Over the last 2 weeks, how many days have you had little interest or pleasure
in doing things?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I9. Over the last 2 weeks, how many days have you felt down, depressed or
hopeless?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I10. Over the last 2 weeks, how many days have you had trouble falling asleep
or staying asleep or sleeping too much?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I11. Over the last 2 weeks, how many days have you felt tired or had little
energy?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I12. Over the last 2 weeks, how many days have you had a poor appetite or
eaten too much?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88

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REFUSED..................... 99
I13. Over the last 2 weeks, how many days have you felt bad about yourself or
that you were a failure or had let yourself or your family down?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I14. Over the last 2 weeks, how many days have you had trouble concentrating
on things, such as reading the newspaper or watching the TV?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
I15. Over the last 2 weeks, how many days have you moved or spoken so slowly
that other people could have noticed? Or the opposite – being so fidgety or
restless that you were moving around a lot more than usual?
01-14 days ................... _ _
None ............................. 00
DON’T KNOW............... 88
REFUSED..................... 99
PTSD
The following questions are about any traumatic experiences.
During the past 30 days have you …..
I16. Had nightmares about the oil spill or any clean-up efforts you engaged in or
thought about it when you did not want to?
Yes.................................. 1
No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9
I17. Tried hard not to think about the oil spill or any clean-up efforts you engaged
in or went out of your way to avoid situations that remind you of it?
Yes.................................. 1
No ................................... 2
DON’T KNOW................ .8
REFUSED....................... 9
I18. Were constantly on guard, watchful, or easily startled?
Yes.................................. 1
No ................................... 2

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DON’T KNOW................. 8
REFUSED....................... 9
I19. Felt numb or detached from others, activities, or your surroundings?
Yes.................................. 1
No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9
Resiliency / Coping
I’m now going to make some statements and ask if you agree with them or not.
I20. What happens to me in the future mostly depends on me. Would you say
that you….?
Strongly Disagree ...................................1
Disagree .................................................2
Neither Agree nor Disagree ....................3
Agree ......................................................4
Strongly Agree ........................................5
DON’T KNOW…………………………. ....8
REFUSED...............................................9
I21. I can do just about anything I really set my mind to do. Would you say that
you….?
Strongly Disagree ...................................1
Disagree .................................................2
Neither Agree nor Disagree ....................3
Agree ......................................................4
Strongly Agree ........................................5
DON’T KNOW……………………….........8
REFUSED...............................................9
I22. I am confident in my ability to handle unexpected problems. Would you say
that you….?
Strongly Disagree ...................................1
Disagree .................................................2
Neither Agree nor Disagree ....................3
Agree ......................................................4
Strongly Agree ........................................5
DON’T KNOW……………………….........8
REFUSED...............................................9
I23. When I need suggestions about how to deal with a personal problem, I know
there is someone I can turn to. Would you say that you….?
Strongly Disagree ...................................1
Disagree .................................................2

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Neither Agree nor Disagree ....................3
Agree ......................................................4
Strongly Agree ........................................5
DON’T KNOW………………………… .....8
REFUSED...............................................9
Social Support
Now I would like to ask you about your social support system.
[PROGRAMMER NOTE: FOR QUESTIONS I24-26, NUMBER OF YEARS
WILL CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW
≤ OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF DATE OF INTERVIEW
IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “two years”;
IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “three years”]

In the past [YEAR FILL] how often….
I24. Have you had someone willing to listen to you when you need to talk? It
need not always be the same person. Would you say it’s been….?
Always ............................ 1
Usually ............................ 2
Sometimes ...................... 3
Rarely ............................. 4
Never .............................. 5
DON’T KNOW................. 8
REFUSED....................... 9
I25. Have you had contact with people who are in a similar situation? Would you
say it’s been….?
Always ............................ 1
Usually ............................ 2
Sometimes ...................... 3
Rarely ............................. 4
Never .............................. 5
DON’T KNOW................. 8
REFUSED....................... 9
I26. Did you receive practical help, for example financial help, help with
household repairs, or meals provided by others? Would you say it’s been….
Always ............................ 1
Usually ............................ 2
Sometimes ...................... 3
Rarely ............................. 4
Never .............................. 5
DON’T KNOW................. 8
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REFUSED....................... 9
Received Mental Health Care
The following questions are about mental health care you may have received.
[PROGRAMMER NOTE: FOR QUESTION I27, NUMBER OF YEARS WILL
CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW ≤
OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL]; IF DATE OF
INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE
“three years”; IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “four
years”]

I27. Before [YEAR FILL] ago, did you receive any sort of counseling for
problems with your emotions, nerves, or mental health?
Yes.................................. 1
No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9
[PROGRAMMER NOTE: FOR QUESTION I28, NUMBER OF YEARS WILL
CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW ≤
OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF DATE OF INTERVIEW
IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “two years”;
IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “three years”]

I28. In the past [YEAR FILL], have you received any sort of counseling for
problems with your emotions, nerves, or mental health?
Yes.................................. 1
No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9
[PROGRAMMER NOTE: FOR QUESTION I27, NUMBER OF YEARS WILL
CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW ≤
OCTOBER 1, 2011 USE “two years” FOR [YEAR FILL]; IF DATE OF
INTERVIEW IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE
“three years”; IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “four
years”]

I29. Before [YEAR FILL] ago, were you prescribed medication for problems with
your emotions, nerves, or mental health?
Yes.................................. 1
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No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9
[PROGRAMMER NOTE: FOR QUESTION I30, NUMBER OF YEARS WILL
CHANGE BASED ON DATE OF INTERVIEW. IF DATE OF INTERVIEW ≤
OCTOBER 1, 2011 USE “year” FOR [YEAR FILL]; IF DATE OF INTERVIEW
IS BETWEEN OCTOBER 2, 2011 AND OCTOBER 1, 2012 USE “two years”;
IF DATE OF INTERVIEW ≥ OCTOBER 2, 2012 USE “three years”]

I30. In the past [YEAR FILL], were you prescribed medication for problems with
your emotions, nerves, or mental health?
Yes.................................. 1
No ................................... 2
DON’T KNOW................. 8
REFUSED....................... 9

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SECTION J: Occupational History
Now I would like to ask you about your work history.
J1. Have you ever worked shift work?
Yes.................................... 1
No ..................................... 2 [GO TO J7 – current job]
DON’T KNOW................... 8 [GO TO J7 – current job]
REFUSED......................... 9 [GO TO J7 – current job]
J2. How long did you work shift work?
I_I_I_I UNITS
Months .............................. 1
Years ................................ 2
DON’T KNOW................... 8
REFUSED......................... 9

[IF THE RESPONDENT SAYS "FLEXTIME", ETC., PROBE TO
DETERMINE WHETHER THE SHIFT THAT IS WORKED ACTUALLY
FALLS IN A DAY, EVENING, NIGHT, OR ROTATING SHIFT CATEGORY
BEFORE CODING IT AS "ANOTHER SCHEDULE."
HELP AVAILABLE:
Standard Shift Definitions are:
A regular daytime schedule: this is work anytime between 6am and 6pm.
A regular evening shift: this is work anytime between 2pm and midnight.
A regular night shift: this is work anytime between 9pm and 8am.
A rotating shift: a work shift that changes periodically from days to
evenings or nights.
Another schedule includes: a split shift (consisting of two distinct work
periods each day), an irregular schedule arranged by the employer, or
any other schedule]

J3. What type of shift work did you work?
A regular daytime schedule ........1
A regular evening shift ................2
A regular night shift .....................3
A rotating shift .............................4
Another schedule ........................5
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REFUSED...................................8
DON’T KNOW.............................9
J4. Did you often rotate work shifts?
Yes.................................... 1
No ..................................... 2
DON’T KNOW................... 8
REFUSED......................... 9
[IF CURRENTLY EMPLOYED (Telephone questionnaire, E1=1; K8f=1; or
K12=1; or K17=1); ELSE GO TO SECTION K]
Now I would like to ask you a few questions about your current job.
J5. Which of the following best describes the hours you worked in the past 4
weeks?
A regular daytime schedule ......... 1 [GO TO J7]
A regular evening shift ................. 2 [GO TO QUESTION J7]
A regular night shift ...................... 3 [GO TO QUESTION J7]
A rotating shift .............................. 4
Another schedule ......................... 5
DON’T KNOW.............................. 8
REFUSED.................................... 9 [GO TO QUESTION J7]
J6. Which of the following best describes the hours you worked in the past week?
A regular daytime schedule ........1
A regular evening shift ................2
A regular night shift .....................3
A rotating shift .............................4
Another schedule ........................5
REFUSED...................................8
DON’T KNOW.............................9
J7. Do you often rotate work shifts in your current job?
Yes.................................... 1 [GO TO SECTION K]
No ..................................... 2 [GO TO SECTION K]
DON’T KNOW................... 8 [GO TO SECTION K]
REFUSED......................... 9 [GO TO SECTION K]

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SECTION K: Non-occupational Exposures
Now I would like to ask you about your exposure to oil or other chemicals outside
of your work activities, such as in a hobby.
K1. Do you have any of the following hobbies?
K1a. Woodworking or cabinetry
K1b. Boat repair
K1c. Car, motorcycle, or other vehicle repair
K1d. Gardening
K1e. Fishing
K1f. Pottery
K1g. Painting as art work
K1h. Sculpture
K1i. Home repairs or handyman work
K1j. Raising farm animals

YES
1
1
1
1
1
1
1
1
1
1

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NO
2
2
2
2
2
2
2
2
2
2

DK
8
8
8
8
8
8
8
8
8
8

RE
9
9
9
9
9
9
9
9
9
9

National Institute of Environmental Health Sciences (NIEHS)

01/20/11

SECTION L: Lifestyle
[ONLY ASKED ONLY FOR CURRENT SMOKERS (TELEPHONE J3=1, 2 OR 8]
Current Smoking
Now I’m going to ask you some questions about smoking.
L1. How many hours ago did you last smoke?
# OF HOURS AGO ................... [RANGE: 0 - 24]
1-2 DAYS AGO ......................... 71 [GO TO QUESTION L3]
3-4 DAYS AGO ......................... 72 [GO TO QUESTION L3]
5-7 DAYS AGO ......................... 73 [GO TO QUESTION L3]
MORE THAN 7 DAYS AGO...... 74 [GO TO QUESTION L3]
DON'T KNOW .......................... 88
REFUSED................................. 99
L2. How many cigarettes have you smoked in the past 24 hours?
# OF CIGARETTES: __ [RANGE: 0 - 100] [IF 0, PROBE FURTHER TO
CONFIRM]
DON'T KNOW ........... 888
REFUSED ................. 999
[ONLY ASKED ONLY FOR CURRENT DRINKERS (TELEPHONE I3=1, 8 OR 9]
Current Alcohol Consumption
Now I’m going to ask you some questions about drinking alcohol.
L3. How many drinks have you had in the past 24 hours? Count as a drink a can
or bottle of beer; a wine cooler or a glass of wine, champagne, or sherry; a shot
of liquor or a mixed drink or cocktail.
# OF DRINKS: __ __ [RANGE: 0 - 80]
DON'T KNOW .............. 88
REFUSED..................... 99

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SECTION M: Residential History
[INTERVIEWER: READ THE FOLLOWING PROMPT BEFORE ASKING
QUESTIONS M1 TO M6. ASK EACH OF THESE QUESTIONS FOR ONE
RESIDENCE BEFORE MOVING TO THE NEXT RESIDENCE]

I’m now going to ask you about places you have lived for 3 months or more. We’ll
start with where you live now and move backward to your first residence.
M1. What is/was the address of that residence? [INTERVIEWER: IF
RESPONDENT CAN’T REMEMBER THE FULL ADDRESS, ASK FOR A CITY,
STATE AND LANDMARK, IF APPLICABLE. FOR CURRENT RESIDENCE
INSERT CURRENT ADDRESS]
__________________________ [ADDRESS FIELDS]
DON’T KNOW........ 8
REFUSED.............. 9
M2. What years have/did you live at this/the residence?
_/_/_/_ - _/_/_/_ [YEAR – YEAR]
DON’T KNOW........ 8888 - 8888
REFUSED.............. 9999 – 9999
M3. Did you have a different residence before that?
Yes......................... 1 [REPEAT LOOP M1-M3]
No .......................... 2 [GO TO MATRIX M4-M6]
DON’T KNOW........ 8 [GO TO MATRIX M4-M6]
REFUSED.............. 9 [GO TO MATRIX M4-M6]

[CAPI: REPEAT M1 - M3 UNTIL AGE 18; THEN PRESENT M4 – M8 FOR
EACH ADDRESS NAMED]

M4. Was [FILL PARTIAL ADDRESS] on a farm?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
M5. What was your usual water supply?
City......................... 1
Private Well............ 2
Filtered Water ........ 3
Bottled Water ......... 4

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Other...................... 5 M5a. Specify___________________[FREE TEXT FIELD]
DON’T KNOW........ 8
REFUSED.............. 9
M6. Did you live within ¼ mile of a farm?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
M7. Was this near fields or orchards?
Yes......................... 1
No ......................... 2
DON’T KNOW........ 8
REFUSED.............. 9
M8. Did you live close to the center or margin of town?
Center .................... 1
Margin.................... 2
DON’T KNOW........ 8
REFUSED.............. 9
END MATRIX

M7. Before age 18, did you live at least half your life on a farm?
Yes......................... 1
No .......................... 2
DON’T KNOW........ 8
REFUSED.............. 9

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SECTION N: Experiences with Hurricane Katrina
Now I would like to ask you some questions regarding your experiences with
Hurricane Katrina.
N1. Were you living in the gulf region at the time of Hurricane Katrina
Yes......................... 1
No .......................... 2 [GO TO QUESTION N7]
DON’T KNOW........ 8 [GO TO QUESTION N7]
REFUSED.............. 9 [GO TO QUESTION N7]
N1a. Please provide city and state that you lived in at the time of
Hurricane Katrina.
City_________________________ [FREE TEXT FIELD]
State ________________________[DROP-DOWN MENU]
N2. Were you forced to leave your residence because of the Hurricane?
Yes......................... 1
No .......................... 2 [GO TO QUESTION N7]
DON’T KNOW........ 8
REFUSED.............. 9 [GO TO QUESTION N7]
N3. Where did you go?
_____________________________ [FREE TEXT FIELD]
N4. After the hurricane, did you return to your prior residence or to a different
residence?
Prior ................................. 1 [GO TO QUESTION N6]
Different ........................... 2
Didn’t return ..................... 3
DON’T KNOW........ .......... 8
REFUSED.............. .......... 9 [GO TO QUESTION N7]
N5. Was your new residence in the same city or town and neighborhood?
Same city or town, same neighborhood ...................... 1
Same city or town, different neighborhood................... 2
Different city or town ................................................... 3
DON’T KNOW.............................................................. 8
REFUSED.................................................................... 9 [GO TO QUESTION N7]
N5a. What type of building was this new residence?
Single family house .......... 1
Multi-family house ............ 2
Apartment ......................... 3
Trailer ............................... 4
Other ................................. 5 (Specify): ________________

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DON’T KNOW ................... 8
REFUSED ......................... 9 [GO TO QUESTION N7]
[IF N4 = 3, GO TO N7]
N6. For how many months were you unable to return?
| __ | __ | Months
N7. Did you lose your job as a result of the Hurricane?
Yes .........................................................1
No .......................... ................................2 [GO TO QUESTION N9]
Was unemployed before the Hurricane...3
DON’T KNOW........ ................................8
REFUSED.............. ................................9 [GO TO QUESTION N9]
N8.How long were you unemployed after the Hurricane?
| __ | __ | # of units
Days.................................................................................................. 1
Weeks............................................................................................... 2
Months .............................................................................................. 3
Years ................................................................................................ 4
HAVE NOT WORKED SINCE THE HURRICANE ............................ 66
DID NOT WORK UNTIL THE OIL SPILL CLEAN-UP ....................... 77
DON’T KNOW................................................................................... 88
REFUSED......................................................................................... 99
N9. Did you experience the loss of a loved one or a serious injury to you or a
loved one during the Hurricane?
Yes......................... 1
No .......................... 2 [GO TO SECTION O]
DON’T KNOW........ 8 [GO TO SECTION O]
REFUSED.............. 9 [GO TO SECTION O]
N9a. Please describe this loss or injury [SELECT ALL THAT APPLY]:
Event
Person
Death
Self
Injury
Spouse/partner
Other (Specify): ______________
Child
Brother
Sister
Father
Mother
Other (Specify): ________________
Death
Injury
Other (Specify): ______________

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Self
Spouse/partner
Child

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Brother
Sister
Father
Mother
Other (Specify): ________________
Death
Injury
Other (Specify): ______________

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Self
Spouse/partner
Child
Brother
Sister
Father
Mother
Other (Specify): ________________

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SECTION O: Physical Activity

READ: I am going to ask you about the time you spent being physically active in the last
7 days. Please answer each question even if you do not consider yourself to be an
active person. Think about the activities you do at work, as part of your house and yard
work, to get from place to place, and in your spare time for recreation, exercise or sport.

READ: Now, think about all the vigorous activities which take hard
physical effort that you did in the last 7 days. Vigorous activities make you
breathe much harder than normal and may include heavy lifting, digging,
aerobics, or fast bicycling. Think only about those physical activities that
you did for at least 10 minutes at a time.
O1.

During the last 7 days, on how many days did you do vigorous physical
activities?
_____ Days per week [VDAY; Range 0-7, 8,9]
8.
Don't Know/Not Sure
9.
Refused

[Interviewer clarification: Think only about those physical activities that
you do for at least 10 minutes at a time.]
[Interviewer note: If respondent answers zero, refuses or does not know,
skip to Question 3]
O2.

How much time did you usually spend doing vigorous physical activities
on one of those days?
[VDHRS; Range: 0-16]
__ __ Hours per day
__ __ __ Minutes per day
998.
999.

[VDMIN; Range: 0-960, 998, 999]

Don't Know/Not Sure
Refused

[Interviewer clarification: Think only about those physical activities you
do for at least 10 minutes at a time.]
[Interviewer probe: An average time for one of the days on which you do
vigorous activity is being sought. If the respondent can't answer because
the pattern of time spent varies widely from day to day, ask: "How much
time in total would you spend over the last 7 days doing vigorous
physical activities?”
__ __ Hours per week
[VWHRS; Range: 0-112]

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__ __ __ __Minutes per week
9998. Don't Know/Not Sure
9999. Refused

01/20/11

[VWMIN; Range: 0-6720, 9998, 9999]

READ: Now think about activities which take moderate physical effort that
you did in the last 7 days. Moderate physical activities make you breathe
somewhat harder than normal and may include carrying light loads,
bicycling at a regular pace, recreational fishing or hunting. Do not include
walking. Again, think about only those physical activities that you did for
at least 10 minutes at a time.
O3.

During the last 7 days, on how many days did you do moderate physical
activities?
____ Days per week [MDAY; Range: 0-7, 8, 9]
8.
Don't Know/Not Sure
9.
Refused
[Interviewer clarification: Think only about those physical activities that
you do for at least 10 minutes at a time]
[Interviewer Note: If respondent answers zero, refuses or does not know,
skip to Question O5]

O4.

How much time did you usually spend doing moderate physical activities
on one of those days?
__ __ Hours per day [MDHRS; Range: 0-16]
__ __ __ Minutes per day [MDMIN; Range: 0-960, 998, 999]
998. Don't Know/Not Sure
999. Refused
[Interviewer clarification: Think only about those physical activities that
you do for at least 10 minutes at a time.]
[Interviewer probe: An average time for one of the days on which you do
moderate activity is being sought. If the respondent can't answer because
the pattern of time spent varies widely from day to day, or includes time
spent in multiple jobs, ask: “What is the total amount of time you spent
over the last 7 days doing moderate physical activities?”
__ __ __ Hours per week
[MWHRS; Range: 0-112]
__ __ __ __Minutes per week [MWMIN; Range: 0-6720, 9998, 9999]
9998. Don't Know/Not Sure
9999. Refused

READ: Now think about the time you spent walking in the last 7 days. This includes at
work and at home, walking to travel from place to place, and any other walking that you
might do solely for recreation, sport, exercise, or leisure.

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O5.

01/20/11

During the last 7 days, on how many days did you walk for at least 10
minutes at a time?
____ Days per week [WDAY; Range: 0-7, 8, 9]
8.
Don't Know/Not Sure
9.
Refused
[Interviewer clarification: Think only about the walking that you do for at
least 10 minutes at a time.]
[Interviewer Note: If respondent answers zero, refuses or does not know,
skip to Question O7]

O6.

How much time did you usually spend walking on one of those days?
__ __ Hours per day [WDHRS; Range: 0-16]
__ __ __ Minutes per day [WDMIN; Range: 0-960, 998, 999]
998. Don't Know/Not Sure
999. Refused
[Interviewer probe: An average time for one of the days on which you
walk is being sought. If the respondent can't answer because the pattern
of time spent varies widely from day to day, ask: “What is the total amount
of time you spent walking over the last 7 days?”
__ __ __ Hours per week [WWHRS; Range: 0-112]
__ __ __ __Minutes per week
[WWMIN; Range: 0-6720, 9998, 9999]
9998. Don't Know/Not Sure
9999. Refused

READ: Now think about the time you spent sitting on week days during the last 7 days.
Include time spent at work, at home, and during leisure time. This may include time
spent sitting at a desk, visiting friends, reading or sitting or lying down to watch television
or playing video games, driving or riding in a car or bus.

O7. During the last 7 days, how much time did you usually spend sitting on a
week day?
__ __ Hours per weekday [SDHRS; 0-16]
__ __ __ Minutes per weekday
998. Don't Know/Not Sure
999. Refused

[SDMIN; Range: 0-960, 998, 999]

[Interviewer clarification: Include time spent lying down (awake) as well
as
sitting]

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[Interviewer probe: An average time per day spent sitting is being sought.
If the respondent can't answer because the pattern of time spent varies
widely from day to day, ask: “What is the total amount of time you spent
sitting last Wednesday?”
__ __ Hours on Wednesday
[SWHRS; Range 0-16]
__ __ __ Minutes on Wednesday [SWMIN; Range: 0-960, 998, 999]
998. Don't Know/Not Sure
999. Refused

SECTION P: Fish Consumption
The next set of questions is about seafood you may have eaten since the oil spill.
P1. How often have you eaten raw seafood that came directly from the Gulf since
the oil spill in April 2010?
Never ................................ 1 [GO TO QUESTION P2]
Once ................................. 2
2-5 times ........................... 3
5-10 times ......................... 4
More than 10 times ........... 5
DON’T KNOW................... 8 [GO TO QUESTION P2]
REFUSED......................... 9 [GO TO QUESTION P2]
P1a. What types of raw seafood have you eaten?
________________________[FREE TEXT FIELD]
DON’T KNOW ........ 8
REFUSED .............. 9
P2. How often have you eaten cooked seafood that came directly from the Gulf
since the oil spill in April 2010?
Never ................................ 1 [GO TO SECTION Q]
Once ................................. 2
2-5 times ........................... 3
5-10 times ......................... 4
More than 10 times ........... 5
DON’T KNOW................... 8 [GO TO SECTION Q]
REFUSED......................... 9 [GO TO SECTION Q]
P2. What types of cooked seafood have you eaten?
________________________[FREE TEXT FIELD]
DON’T KNOW ........ 8

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REFUSED .............. 9

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SECTION Q: Social Security Number And Transition
[PROGRAMMER NOTE: SHOW ONLY IF SSN IS MISSING; REFER TO
TELEPHONE SECTION L.1]
Q1. Your social security number will help us keep in touch with you over the
years and allow us to link to the correct records about your health. Reporting
your social security number is voluntary. We will not share your social security
number with others and we will do everything possible to keep it private. What is
your social security number?
__/__/__/ - __/__/ - __/__/__/__/ [GO TO SECTION R]
DON’T HAVE................................. 000 00 0000 [GO TO SECTION R]
DON’T KNOW................................. 888 88 8888
REFUSED....................................... 999 99 9999
Q2. Would you be willing to tell me the last four digits of your social
security number? The last four digits of your Social Security Number are
not unique to you. Other people have those same last four digits.
However, it will help us do a better job of keeping up with you and your
public health records over the years.
Last 4 numbers of SSN - __ __ __ __
DON’T HAVE................................. 0
DON’T KNOW................................. 8
REFUSED....................................... 9

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Part 6: Scripts and Administrative
Modules Post-Home Visit Questionnaire
(Estimated Burden: 1 minute)

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SECTION R: Conclusion of Home Visit
SECTION R.1: Active Subcohort
Thank you for completing the home visit. We very much appreciate your
participation. Over the course of the study, we’ll stay in touch with you and we’ll
ask you to:
•
•

update us each year on any changes to your contact information
complete a short questionnaire every other year by phone

Do you have any questions? As you think of additional questions, here is the tollfree number you can call and the web-site address for the study that has helpful
information.
We thank you very much for your help.
[CONCLUDE VISIT]
SECTION R.2: Biomedical Surveillance Subcohort
Thank you for completing the home visit. We very much appreciate your
participation. Over the course of the study, we’ll stay in touch with you and we’ll
ask you to:
•
•

update us each year on any changes to your contact information
complete a short questionnaire every other year by phone

You may also be invited to take part in more detailed clinical studies with our
research collaborators who live in your area. The purpose and requirements of
these studies will be explained to you before you’re enrolled, and you can decide
whether or not you want to participate. You’ll receive additional reimbursements
for participating in these studies.
Do you have any questions? As you think of additional questions, here is the tollfree number you can call and the web-site address for the study that has helpful
information.
We thank you very much for your help.
[CONCLUDE VISIT]

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Section S: Medical Referral

S1. WAS A MEDICAL REFERRAL PROVIDED?
YES ........................1
NO ..........................2 [GO TO SECTION T]
S2. PLEASE PROVIDE THE REFERRAL INFORMATION: [PROGRAMMER
NOTE: PLEASE PROGRAM 5 LOOPS]
DOCTOR NAME ____________________________
PRACTICE NAME ___________________________
ADDRESS _________________________________
CITY ______________________________________
STATE ____________________________________
ZIP CODE _________________________________
PHONE ___________________________________
S2a. REASON FOR REFERRAL
[NARRATIVE FIELD]

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[FREE TEXT FIELD]
[FREE TEXT FIELD]
[FREE TEXT FIELD]
[FREE TEXT FIELD]
[FREE TEXT FIELD]
[FREE TEXT FIELD]
[FREE TEXT FIELD]

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SECTION T: Incident Report
T1. WHAT IS THE REASON FOR THIS INCIDENT REPORT?
[SELECT ALL THAT APPLY]
1. NO INCIDENT REPORT NECESSARY ........................................1 [GO TO
SECTION U]
2. ACUTE MEDICAL PROBLEM .......................................................2
3. ACUTE MENTAL HEALTH PROBLEM .........................................3
4. OBSERVED CHILD ABUSE OR NEGLECT..................................4
5. POSSIBLE ABUSE OR NEGLECT OF OTHERS IN THE HOME .5
6. OBSERVED ELDER ABUSE OR NEGLECT ................................6
7. POSSIBLE ABUSE OF SPOUSE
OR PARTNER (NOT THE PARTICIPANT) ......................................7
8. POSSIBLE ABUSE OF SPOUSE
OR PARTNER (PARTICIPANT) ........................................................8
T1.8.a. DID THE PARTICIPANT REQUEST INFORMATION ON
OBTAINING
ASSISTANCE?
YES ...................1
NO.....................2
T2. DESCRIBE THE REASON FOR THIS REPORT, INCLUDING A REASON
FOR EACH ANSWER SELECTED IN T1, IF APPLICABLE.
________________[FREE TEXT FIELD]
T3. WHAT ACTION WAS TAKEN AS A RESULT?
[SELECT ALL THAT APPLY]
1. 911 OR OTHER EMERGENCY SERVICES NOTIFIED
2. ASSISTED PARTICIPANT IN RECEIVING EMERGENCY MEDICAL
SERVICES
3. OFFERED TO CALL 911 OR ASSIST PARTICIPANT IN OBTAINING
EMERGENCY MEDICAL SERVICES, BUT OFFER WAS DECLINED
4. NOTIFIED REGIONAL MANAGER
5. NOTIFIED SRA
6. ENDED VISIT
7. PROCEEDED WITH YOUR EVALUATION BECAUSE SUSPICION OF
ABUSE OR NEGLECT DID NOT WARRANT IMMEDIATE ACTION
8. OTHER
T3.8.a. DESCRIBE OTHER ACTIONS TAKEN.
________
[FREE TEXT FIELD]

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SECTION U: Follow-up Calls

U1. DID THE PARTICIPANT RECEIVE AN INITIAL FOLLOW-UP CALL?
YES………………1
NO………………..2 [GO TO QUESTION U2]
U1a. RECORD THE DATE OF THE CALL.
__/__/____ [MM/DD/YYYY]
U1b. RECORD THE TIME OF THE CALL.
__:__
AM………1
PM………2
U1c. DID YOU SPEAK WITH THE PARTICIPANT?
YES………..1
NO…………2
U1d. RECORD ANY ADVICE AND REFERRALS GIVEN TO THE
PARTICIPANT.
______________[FREE TEXT FIELD]
U2. DID THE PARTICIPANT RECEIVE A SECOND FOLLOW-UP CALL?
YES………………1
NO………………..2 [GO TO END]
U2a. RECORD THE DATE OF THE CALL.
__/__/____ [MM/DD/YYYY]
U2b. RECORD THE TIME OF THE CALL.
__:__
AM………1
PM………2
U2c. DID YOU SPEAK WITH THE PARTICIPANT?
YES………..1
NO…………2
U2d. RECORD ANY ADVICE AND REFERRALS GIVEN TO THE
PARTICIPANT.
______________[FREE TEXT FIELD]

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SECTION V: Shipping
V1. WAS FEDEX USED FOR SHIPPING?
YES..............1
NO ...............2 [GO TO QUESTION V2]
V1a. RECORD THE FEDEX SHIPMENT TRACKING NUMBER.
[FREE TEXT FIELD]
V1b. RECORD THE FEDEX SHIPPING LOCATION.
[FREE TEXT FIELD]
V1c. RECORD DATE AND TIME THAT THE SHIPMENT WAS
DELIVERED TO FEDEX.
DATE: __ __/ __ __/__ __ __ __ [MM/DD/YYYY]
TIME: __/__/ : __/__/
AM............... 1
PM............... 2

V2. WAS WORLD COURIER USED FOR SHIPPING?
YES ............. 1
NO............... 2
V2a. RECORD THE WORLD COURIER SHIPMENT TRACKING
NUMBER.
[FREE TEXT FIELD]
V2b. RECORD THE WORLD COURIER SHIPPING LOCATION.
[FREE TEXT FIELD]
V2c. RECORD DATE AND TIME THAT THE SHIPMENT WAS
DELIVERED TO WORLD COURIER.
DATE: __ __/ __ __/__ __ __ __ [MM/DD/YYYY]
TIME: __/__/ : __/__/
AM ............... 1
PM ............... 2
[CAPI: SET WARNING FLAG: IF V1 AND V2 BOTH EQUAL NO, THEN
ERROR MESSAGE]

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