Health Survey

OMB Control Number: 0923-0042

Expiration Date: 11/30/2013

ATSDR Health Survey of

Marine Corps Personnel

and Civilians

Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0923-0042).

Instructions for Completing the Survey

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

• Mark X to indicate your answer.

• If you want to change your answer, completely fill in the answer box for the wrong answer X and mark X in the box next to the correct answer.

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

• When entering numbers, fill all boxes. For example, enter “4” as “0 4”.

IMPORTANT

PLEASE BE SURE TO SIGN THE INFORMED CONSENT FORM ON THE PREVIOUS PAGE. AN EXTRA COPY IS INCLUDED FOR YOU TO KEEP.

A1. Questions in this survey ask about the person named below. Are you this person? <NAME OF PARTICIPANT> Yes  GO TO Section B, Residential History, on page XX No A2. Is the person named in A1 deceased or is he/she unable to complete this survey for some other reason? Deceased Unable to complete Thank you for completing this survey on behalf of the person named in A1. Please answer questions A3 and A4 about yourself. A3. What is your name? First: ________________________________ Middle: _________________________ Last: ________________________________ Suffix (Jr., Sr., etc.): _____

A4. What is your relationship to the person named in A1? Husband/Wife  GO TO A5 Brother/Sister Parent Child Other-specify:___________________ A5. Were you living with this person during time he/she was living or working at Camp Lejeune or Camp Pendleton? Yes No IMPORTANT If you are answering this survey on behalf of the person in A1, please answer all questions about that person, not yourself.

B. Residential History

B1. Did you live on base at Camp Lejeune or Camp Pendleton? Yes, active duty  GO TO B2 Yes, civilian worker  GO TO B4 Yes, living with someone who was active duty or a civilian worker  GO TO B3 No, did not live on base  GO TO Section C, Medical History, on next page B2. What unit(s) were you assigned to? _____________________________ ___________________________ B3. What is the full name of that person? _______________________________ B4. Thinking about the first place you lived on base, was it at Camp Lejeune or Camp Pendleton? Camp Lejeune Camp Pendleton B5. What was the location or address where you resided (location of barracks/street address/family housing area)? ________________________________ _________________________________ B6. When did you start living there (month and year)? / m m y y y y B7. When did you stop living there (month and year)? / m m y y y y

B8. Were there any other places you lived on base at Camp Lejeune or Camp Pendleton? Yes, Camp Lejeune Yes, Camp Pendleton No  GO TO Section C, Medical History, on next page B9. What was the location or address where you resided (location of barracks/street address/family housing area)? ________________________________ ________________________________ B10. When did you start living there (month and year)? / m m y y y y B11. When did you stop living there (month and year)? / m m y y y y B12. Were there any other places you lived on base at Camp Lejeune or Camp Pendleton? Yes, Camp Lejeune Yes, Camp Pendleton No  GO TO Section C, Medical History, on next page B13. What was the location or address where you resided (location of barracks/street address/family housing area)? _______________________________ ________________________________

B14. When did you start living there (month and year)? / m m y y y y B15. When did you stop living there (month and year)? / m m y y y y B16. Were there any other places you lived on base at Camp Lejeune or Camp Pendleton? Yes, Camp Lejeune Yes, Camp Pendleton No  GO TO Section C, Medical History, in next column B17. What was the location or address where you resided (location of barracks/street address/family housing area)? _____________________________________ _____________________________________ B18. When did you start living there (month and year)? / m m y y y y B19. When did you stop living there (month and year)? / m m y y y y

C. Medical History We are interested in finding out about any diseases, medical conditions, or illnesses you may have had. Remember: If you are answering this survey on behalf of the person listed in A1, please answer all questions about that person, not yourself. C1. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been told by a doctor or other health care provider that you had cancer or a malignancy of any kind? Yes No  GO TO Section D, Other Health Conditions, on page XX C2. Thinking of your first diagnosed cancer, what kind of cancer was it? Mark only one answer. Appendix Mouth/Tongue/Lip Bladder Multiple Myeloma Bone Ovary Brain Pancreas Breast Prostate Cervix Rectum Colon Esophagus Small intestine Gallbladder Soft tissue (muscle or fat) Kidney Stomach Larynx or Windpipe Testicle Leukemia Throat or Pharynx Liver Thyroid Lung Uterus Lymphoma Other-specify: __________________ Melanoma Don't know

C3. How old were you when this cancer was first diagnosed? years old C4. Was this: A primary cancer, or A cancer that had spread or metastasized from somewhere else in the body? C5. What state were you living in when this cancer was first diagnosed? _________________________ C6. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been diagnosed with any other kind of cancer? Yes No  GO TO Section D, Other Health Conditions, on next page C7. What kind of cancer was this? Mark only one answer. Appendix Mouth/Tongue/Lip Bladder Multiple Myeloma Bone Ovary Brain Pancreas Breast Prostate Cervix Rectum Colon Small intestine Esophagus Soft tissue (muscle or fat) Gallbladder Stomach Kidney Testicle Larynx or Windpipe Throat or Pharynx Leukemia Thyroid Liver Uterus Lung Other-specify: __________________ Lymphoma Melanoma Don't know

C8. How old were you when this cancer was first diagnosed? years old C9. Was this: A primary cancer, or A cancer that had spread or metastasized from somewhere else in the body? C10. What state were you living in when this second cancer was first diagnosed? _________________________________ C11. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been diagnosed with any other kinds of cancer? Yes No  GO TO Section D, Other Health Conditions, on next page C12. What kinds of cancer were they? Please mark all that apply. Appendix Mouth/Tongue/Lip Bladder Multiple Myeloma Bone Ovary Brain Pancreas Breast Prostate Cervix Rectum Colon Small intestine Esophagus Soft tissue (muscle or fat) Gallbladder Stomach Kidney Testicle Larynx or Windpipe Throat or Pharynx Leukemia Thyroid Liver Uterus Lung Other-specify: __________________ Lymphoma Don't know Melanoma

D. Other Health Conditions

Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you ever been told by a doctor or other health care provider that you had any of the following conditions. D1. Have you been told you had kidney disease or kidney failure? Do not include kidney cancer, kidney stones, bladder infection or incontinence. Yes No  GO TO D4 D2. What was the name of your kidney disease? ____________________________________ D3. How old were you when this was first diagnosed? years old D4. Have you been told you had liver disease? Do not include liver cancer. Yes No  GO TO D7 in next column D5. What was the name of the liver disease? Necrosis Cirrhosis Liver Failure Fatty Liver Other–specify: ____________________ D6. How old were you when this was first diagnosed? years old

D7. Have you been told you had lupus? Yes No  GO TO D9 D8. How old were you when this was first diagnosed? years old D9. Have you been told you had scleroderma? Yes No  GO TO D11 D10. How old were you when this was first diagnosed? years old D11. Have you been told you had Parkinson’s Disease? Yes No  GO TO D13 D12. How old were you when this was first diagnosed? years old D13. Have you been told you had Multiple Sclerosis (MS)? Yes No GO TO D15 on next page D14. How old were you when this was first diagnosed? years old

D15. Have you been told you had Amyotrophic Lateral Sclerosis (also known as ALS or “Lou Gehrig’s Disease”) or some other motor neuron disease?

Yes

No  GO TO D17

D16. How old were you when this was first diagnosed?

years old

D17. Have you been told you had aplastic anemia?

Yes

No  GO TO D19

D18. How old were you when this was first diagnosed?

years old

D19. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been told by a doctor or other health care provider that you had a persistent skin rash or dermatitis?

Yes

No  GO TO D26 on next page

D20. Did you have hepatitis at the same time you had the skin rash or dermatitis?

Yes

No

D21. What was the name of the skin rash or dermatitis?

_________________________________

_________________________________

D22. How old were you when this was first diagnosed?

years old

D23. How long did your skin rash or dermatitis last?

Less than a week

1–3 weeks

1 month

2–5 months

6 months–1 year

More than 1 year

D24. Where on your body did your skin rash or dermatitis occur?

Mark all that apply.

Head	Stomach
Face	Legs
Arms	Feet
Hands	Other-specify: ____________________
Chest
Back

D25. What were the symptoms of your skin rash or dermatitis?

Mark all that apply.

Redness	Blisters
Swelling	Fissures or cracks
Itching	Oozing
Dry skin with scaling/flaking	Bleeding
Crusts	Other–specify: __________________

D26. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been told by a doctor or other health care provider that you were infertile? Do not include your partner’s infertility, if any.

Yes

No  GO TO Section E, Additional Health

Conditions, in next column

D27. What did your doctor or other health care provider tell you was the reason for your infertility?

Mark all that apply.

Fallopian tube damage or blockage	Abnormal sperm
Endometriosis	Low sperm count
Advanced age	Impotence
Ovulation disorders/ Polycystic Ovary Syndrome (PCOS)	Unexplained infertility
Uterine fibroids/ Other uterine problems	Other–specify: ____________________________________

D28. How old were you when this was first diagnosed?

years old

E. Additional Health Conditions

Remember:

If you are answering this survey on behalf of the person listed in A1, please answer all questions about that person, not yourself.

E1. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you had any other serious health conditions that have not been covered above?

Yes

No  GO TO E3

E2. Please list them below.

a. __________________________________

__________________________________

b. __________________________________

__________________________________

c. __________________________________

__________________________________

d. __________________________________

__________________________________

e. __________________________________

___________________________________

E3. Are you:

Female  GO TO Section F, Reproductive

History, on next page

Male  GO TO Section G, Occupational

History, on page XX

Reproductive History (WOMEN ONLY)

F1. Between the time you first lived or worked at Camp Lejeune or Camp Pendleton and the present time, have you been told by a doctor or other health care provider that you had endometriosis? Yes No  GO TO F3 F2. How old were you when this was first diagnosed? years old F3. Have you ever been pregnant? Yes No  GO TO Section G, Occupational History, on page XX F4. Have you ever had a pregnancy that resulted in a live birth? Yes No F5. Were you pregnant during the time you lived or worked at Camp Lejeune or Camp Pendleton? Yes No  GO TO Section G, Occupational History, on page XX F6. How many times were you pregnant during the time you lived or worked at Camp Lejeune or Camp Pendleton? No. of pregnancies QUESTION 1QUESTION 1	The following questions apply only to pregnancies that occurred during the time you lived or worked at Camp Lejeune or Camp Pendleton. Please complete all of the questions for each pregnancy during this time. PREGNANCY #1 F7. When did your first pregnancy end? (month/year) / m m y y y y F8. What was the outcome of this pregnancy? Live birth of single child Live birth of multiple children Tubal pregnancy Elective abortion Miscarriage or stillbirth F9. How many weeks were you when the pregnancy ended? weeks F10. Did you have a positive pregnancy test before miscarriage/stillbirth occurred? Yes No F11. Was the miscarriage/stillbirth confirmed by a doctor or other health care provider? Yes No F12. Did this pregnancy involve a birth defect? Yes No  GO TO F14 on next page GO TO F13 on next page
F13. If yes, what is the name of the birth defect? _______________________________ _______________________________ F14. Did you have another pregnancy during the time you lived or worked at Camp Lejeune or Camp Pendleton? Yes No  GO TO Section G, Occupational History, on page XX PREGNANCY #2 F15. When did your second pregnancy end? (month/year) / m m y y y y F16. What was the outcome of this pregnancy? Live birth of single child Live birth of multiple children Tubal pregnancy Elective abortion Miscarriage or stillbirth F17. How many weeks were you when the pregnancy ended? weeks F18. Did you have a positive pregnancy test before the miscarriage/stillbirth occurred? Yes No F19. Was the miscarriage/stillbirth confirmed by a doctor or other health care provider? Yes No GO TO F20 in next column	F20. Did this pregnancy involve a birth defect? Yes No  GO TO F22 F21. If yes, what is the name of the birth defect? _______________________________ _______________________________ F22. Did you have another pregnancy during the time you lived or worked at Camp Lejeune or Camp Pendleton? Yes No  GO TO Section G, Occupational History, on page XX PREGNANCY #3 F23. When did your third pregnancy end? (month/year) / m m y y y y F24. What was the outcome of this pregnancy? Live birth of single child Live birth of multiple children Tubal pregnancy Elective abortion Miscarriage or stillbirth F25. How many weeks were you when the pregnancy ended? weeks F26. Did you have a positive pregnancy test before the miscarriage/stillbirth occurred? Yes No GO TO F28 on next page
F27. Was the miscarriage/stillbirth confirmed by a doctor or other health care provider? Yes No F28. Did this pregnancy involve a birth defect? Yes No  GO TO F30 F29. If yes, what is the name of the birth defect? _______________________________ _______________________________ F30. Did you have another pregnancy during the time you lived or worked at Camp Lejeune or Camp Pendleton? Yes No  GO TO Section G, Occupational History, on next page PREGNANCY #4 F31. When did your fourth pregnancy end? (month/year) / m m y y y y F32. What was the outcome of this pregnancy? Live birth of single child Live birth of multiple children Tubal pregnancy Elective abortion Miscarriage or stillbirth F33. How many weeks were you when the pregnancy ended? weeks GO TO F36 in next column	F34. Did you have a positive pregnancy test before the miscarriage/ stillbirth occurred? Yes No F35. Was the miscarriage/stillbirth confirmed by a doctor or other health care provider? Yes No F36. Did this pregnancy involve a birth defect? Yes No  GO TO Section G, Occupational History, on next page F37. If yes, what is the name of the birth defect? _______________________________ _______________________________

G. Occupational History

We are interested in exposures to

hazardous materials from jobs that you

have held since the time you first lived or

worked at Camp Lejeune or Camp

Pendleton up until the present time. This

includes any part-time and full-time

military and civilian jobs, or jobs on a

farm that lasted at least one month or

longer.

G1. Since you first lived or worked at Camp Lejeune or Camp Pendleton up until the present time, did you work with or were you exposed to any of the following in any of your jobs:

	Yes No
a. Pesticides, herbicides, fungicides, insecticides, or rat poison?
b. Radiation, such as x- rays, radar, or electro-magnetic fields (EMFs)?
c. Metals such as lead, mercury, nickel, cadmium, or arsenic?
d. Solvents such as paint thinners, paints, glues, metal degreasing agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?
e. Other chemicals or hazardous substances such as asbestos or chlorine?

G2. Did you answer “Yes” to any of the items above (a-e)?

Yes

No  GO TO Section H, Service in

Vietnam, on page XX

G

O TO Job #1 in next column

J OB #1

Starting with the time you first worked

or lived at Camp Lejeune or Camp

Pendleton up until the present time,

please tell us about the first job where

you worked with or were exposed to

pesticides, radiation, metals, solvents,

or other chemicals or hazardous

substances.

G3. Was this job on base at Camp Lejeune or Camp Pendleton?

Yes, at Camp Lejeune

Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton  GO TO G5

G4. Please specify the area on base

where you worked (that is, address

or building number).

_____________________________

_____________________________

G5. What was the name and location of

the company or organization you

worked for?

_____________________________

______________________________

G6. In what month and year did you start this job?

/  

m m y y y y

G7. In what month and year did you end this job?

/  

m m y y y y

G8. What was your job title?

_______________________________

G9. What were your main activities or

duties on this job?

________________________________

________________________________

________________________________

G10. Did you usually work part-time or full-

time?

Part-time

Full-time

G11. In this job, did you work with or were

you exposed to pesticides, herbicides,

fungicides, insecticides, or rat poison?

Yes

No  GO TO G12

1. Name of chemical(s): ______________

________________________________

G12. In this job, did you work with or were

you exposed to radiation such as x-

rays, radar, or electro-magnetic fields

(EMFs)?

Yes

No  GO TO G13

1. Kind of radiation: _________________

_________________________________

G13. In this job, did you work with or were

you exposed to metals such as lead,

mercury, nickel, cadmium, or arsenic?

Yes

No  GO TO G14 in next column

1. Name of metal(s): __________________

__________________________________

G14. In this job, did you work with or

were you exposed to solvents such

as paint thinners, paints, glues,

metal degreasing agents, toluene,

carbon disulfide,

trichloroethylene, or carbon

tetrachloride?

Yes

No  GO TO G15

1. Name of solvent(s) : __________

____________________________

G15. In this job, did you work with or

were you exposed to other

chemicals or hazardous substances

such as asbestos or chlorine?

Yes

No  GO TO G16

1. Name of other material(s): _______

______________________________

______________________________

G16. Did you have any other jobs after this one up until the present time that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances?

Yes

No  GO TO Section H, Service

in Vietnam, on page XX

JOB #2

G17. Was this job on base at Camp Lejeune or Camp Pendleton?

Yes, at Camp Lejeune

Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton  GO TO G19 on

next page

GO TO G18 on next page

G18. Please specify the area on base

where you worked (that is,

address or building number).

_____________________________

_____________________________

G19. What was the name and location

of the company or organization

you worked for?

_____________________________

_____________________________

G20. In what month and year did you start this job?

/  

m m y y y y

G21. In what month and year did you end this job?

/  

m m y y y y

G22. What was your job title?

_______________________________

G23. What were your main activities or duties on this job?

____________________________________

____________________________________

____________________________________

G24. Did you usually work part-time or full

time?

Part-time

Full-time

G25. In this job, did you work with or were you exposed to pesticides, herbicides, fungicides, insecticides, or rat poison?

Yes

No  GO TO G26 in next column

1. Name of chemical(s): ________________

_______________________________

G26. In this job, did you work with or were you exposed to radiation such as x-rays, radar, or electro-magnetic fields (EMFs)?

Yes

No  GO TO G27

1. Kind of radiation: ______________

_____________________________

G27. In this job, did you work with or were you exposed to metals such as lead, mercury, nickel, cadmium, or arsenic?

Yes

No  GO TO G28

1. Name of metal(s): ______________

____________________________

G28. In this job, did you work with or were you exposed to solvents such as paint thinners, paints, glues, metal degreasing agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Yes

No  GO TO G29

1. Name of solvent(s) : ____________

____________________________

G29. In this job, did you work with or were you exposed to other chemicals or hazardous substances such as asbestos or chlorine?

Yes

No  GO TO G30 on next page

1. Name of other material(s): _______

______________________________

______________________________

G30. Did you have any other jobs after this one up until the present time that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances?

Yes

No  GO TO Section H, Service In

Vietnam, on page XX

JOB #3

G31. Was this job on base at Camp Lejeune or Camp Pendleton?

Yes, at Camp Lejeune

Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton  GO TO G33

G32. Please specify the area on base

where you worked (that is,

address or building number).

_____________________________

_____________________________

G33. What was the name and location

of the company or organization

you worked for?

_____________________________

_____________________________

G34. In what month and year did you start this job?

/  

m m y y y y

G35. In what month and year did you end this job?

/  

m m y y y y

G36. What was your job title?

_______________________________

G37. What were your main activities or

duties on this job?

_______________________________

_______________________________

_______________________________

G38. Did you usually work part-time or

full-time?

Part-time

Full-time

G39. In this job, did you work with or were you exposed to pesticides, herbicides, fungicides, insecticides, or rat poison?

Yes

No  GO TO G40

1. Name of chemical(s): ____________

_____________________________

G40. In this job, did you work with or were you exposed to radiation such as x-rays, radar, or electro-magnetic fields (EMFs)?

Yes

No  GO TO G41

1. Kind of radiation: ________________

______________________________

G41. In this job, did you work with or were you exposed to metals such as lead, mercury, nickel, cadmium, or arsenic?

Yes

No  GO TO G42 on next page

1. Name of metal(s): _______________

______________________________

G42. In this job, did you work with or were you exposed to solvents such as paint thinners, paints, glues, metal degreasing agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

Yes

No  GO TO G43

1. Name of solvent(s) : ________________

________________________________

G43. In this job, did you work with or were you exposed to other chemicals or hazardous substances such as asbestos or chlorine?

Yes

No  GO TO G44

1. Name of other material(s): __________

__________________________________

__________________________________

G44. Did you have any other jobs after this one up until the present time that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances?

Yes

No  GO TO Section H, Service in

Vietnam, on page XX

JOB #4

G45. Was this job on base at Camp Lejeune or Camp Pendleton?

Yes, at Camp Lejeune

Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton  GO TO G47 in next column

G46. Please specify the area on base

where you worked (that is,

address or building number).

_____________________________

_____________________________

GO TO G48 in next column

G47. What was the name and location

of the company or organization

you worked for?

____________________________

_____________________________

G48. In what month and year did you start this job?

/  

m m y y y y

G49. In what month and year did you

end this job?

/  

m m y y y y

G50. What was your job title?

____________________________

G51. What were your main activities or

duties on this job?

_______________________________

_______________________________

_______________________________

G52. Did you usually work part-time or

full- time?

Part-time

Full-time

G53. In this job, did you work with or were you exposed to pesticides, herbicides, fungicides, insecticides, or rat poison?

Yes

No  GO TO G54 on

next page

1. Name of chemical(s):____________

_____________________________

G54. In this job, did you work with or were you exposed to radiation such as x-rays, radar, or electro-magnetic fields (EMFs)? Yes No  GO TO G55 Kind of radiation: _________________ _______________________________ G55. In this job, did you work with or were you exposed to metals such as lead, mercury, nickel, cadmium, or arsenic? Yes No  GO TO G56 Name of metal(s): _________________ _______________________________ G56. In this job, did you work with or were you exposed to solvents such as paint thinners, paints, glues, metal degreasing agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride? Yes No  GO TO G57 Name of solvent(s) : _______________ ________________________________ F57. In this job, did you work with or were you exposed to other chemicals or hazardous substances such as asbestos or chlorine? Yes No  GO TO G58 in next column Name of other material(s): __________ __________________________________ __________________________________

G58. Did you have any other jobs after this one up until the present time that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances?? Yes No  GO TO ‘Service in Vietnam’ section on page XX JOB #5 G59. Was this job on base at Camp Lejeune or Camp Pendleton? Yes, at Camp Lejeune Yes, at Camp Pendleton No, not at Camp Lejeune or Camp Pendleton  GO TO G61 G60. Please specify the area on base where you worked (that is, address or building number). _____________________________ _____________________________ G61. What was the name and location of the company or organization you worked for? _____________________________ _____________________________ G62. In what month and year did you start this job? /   m m y y y y G63. In what month and year did you end this job? /   m m y y y y

G64. What was your job title? ____________________________ G65. What were your main activities or duties on this job? _______________________________ _______________________________ _______________________________ G66. Did you usually work part-time or full- time? Part-time Full-time G67. In this job, did you work with or were you exposed to pesticides, herbicides, fungicides, insecticides, or rat poison? Yes No  GO TO G68 Name of chemical(s): _____________ _______________________________ G68. In this job, did you work with or were you exposed to radiation such as x-rays, radar, or electro-magnetic fields (EMFs)? Yes No  GO TO G69 Kind of radiation: __________________ _______________________________ G69. In this job, did you work with or were you exposed to metals such as lead, mercury, nickel, cadmium, or arsenic? Yes No  GO TO G70 in next column Name of metal(s): ________________ _______________________________

G70. In this job, did you work with or were you exposed to solvents such as paint thinners, paints, glues, metal degreasing agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride? Yes No  GO TO G71 Name of solvent(s) : ______________ ________________________________ G71. In this job, did you work with or were you exposed to other chemicals or hazardous substances such as asbestos or chlorine? Yes No  GO TO G72 Name of other material(s): _________ ________________________________ ________________________________ G72. Did you have any other jobs after this one up until the present time that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances? Yes No  GO TO Section H, Service in Vietnam, on next page GO TO next page

OTHER JOBS Please answer the following questions about all of the other jobs held since the last job you reported that involved working with or being exposed to pesticides, radiation, metals, solvents, or other chemicals or hazardous substances. G73. In any of these jobs, did you work with or were you exposed to pesticides, herbicides, fungicides, insecticides, or rat poison? Yes No  GO TO G75 G74. What is the name of the chemical(s) you worked with or were exposed to? ____________________________________ ____________________________________ G75. In any of these jobs, did you work with or were you exposed to radiation such as x-rays, radar, or electro-magnetic fields (EMFs)? Yes No  GO TO G77 in next column G76. What kind of radiation did you work with or were exposed to? ___________________________________ ___________________________________

G77. In any of these jobs, did you work with or were you exposed to metals such as lead, mercury, nickel, cadmium, or aresenic? Yes No  GO TO G79 G78. What is the name of the metal(s) you worked with or were exposed to? __________________________________ __________________________________ G79. In any of these jobs, did you work with or were you exposed to solvents such as paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride? Yes No  GO TO G81 G80. What is the name of the solvent(s) you worked with or were exposed to? ____________________________________ ____________________________________ G81. In any of these jobs, did you work with or were you exposed to any other chemicals or hazardous substances such as asbestos or chlorine? Yes No  GO TO Section H, Service in Vietnam, on next page G82. What is the name of the other chemical(s) or hazardous substance(s) you worked with or were exposed to? ____________________________________ ____________________________________

H. Service in Vietnam Remember: If you are answering this survey on behalf of the person listed in A1, please answer all questions about that person, not yourself. H1. Were you stationed in Vietnam between 1965 and 1971? Yes No  GO TO Section I, Smoking History, in next column H2. When were you in Vietnam? Mark all years that apply. 1965 1969 1966 1970 1967 1971 1968 H3. In total, how many months or years were you in Vietnam between 1965 and 1971? months OR years H4. Did you ever come into contact with herbicides while you were in Vietnam? For example, did you inhale herbicides or get herbicides on your skin or clothing? Yes No GO TO Section I, Smoking Not sure History, in next column H5. Describe how you came in contact with herbicides. ______________________________ ______________________________

I. Smoking History I1. Have you ever smoked cigarettes? Yes No GO TO I8 on next page I2. Do you smoke cigarettes now? Yes No  GO TO I5 I3. On average, over all the years you have smoked, how many cigarettes per day did you smoke? (1 pack=20 cigarettes) Enter ‘00’ if less than 1 cigarette per day. cigarettes per day I4. In total, how many years have you smoked, excluding any times you may have quit? Enter ‘00’ if less than 1 year. years  GO TO I8 on next page I5. How old were you the last time you quit smoking cigarettes? years old I6. On average, when you were smoking, about how many cigarettes per day did you smoke? (1 pack = 20 cigarettes) Enter ‘00’ if less than 1 cigarette per day. cigarettes per day I7. In total, how many years did you smoke, excluding any times you may have quit? Enter ‘00’ if less than 1 year. years

I8. Have you ever used any other tobacco products (such as chewing tobacco, smokeless tobacco, cigars, a pipe, etc.)? Yes No  GO TO I11 I9. Do you currently use any of these tobacco products? Yes No I10. Which of the following tobacco products have you ever used? Mark all that apply. Chewing tobacco Smokeless tobacco Pipe Cigars Other-specify: ____________________ I11. Have you ever lived for more than 1 year with someone while they were smoking on a daily basis? Yes No  GO TO Section J, Alcohol History, in next column I12. In total, how many years have you lived with someone while they were smoking on a daily basis? 1-3 years 10-12 years 4-6 years 13-15 years 7-9 years 16 or more years I13. During most of this time, how many people living with you smoked on a daily basis? 1 person 2 persons More than 2 persons

J. Alcohol History Remember: If you are answering this survey on behalf of the person listed in A1, please answer all questions about that person, not yourself. The following questions ask about your use of alcohol. J1. Have you ever had a drink of alcohol? Yes No  GO TO Section K, Demographics, on next page J2. At what age did you start drinking alcohol? years old J3. Do you drink alcoholic beverages now? Yes No  GO TO J7 on next page J4. On average, how often do you drink alcoholic beverages? Every day or almost every day 2 to 4 times a week 1 time a week 1 to 3 times a month Less than once a month

J5. When you drink, about how many servings of alcohol do you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor. servings J6. Was there a time in the past when you drank significantly more than you usually drink now? Yes SKIP J7 through J9 No and GO TO Section K, Demographics, in next column J7. How old were you when you stopped drinking alcoholic beverages? years old J8. On average, how often did you drink alcoholic beverages? Almost every day 2 to 4 times a week 1 time a week 1 to 3 times a month Less than once a month J9. When you drank, about how many servings of alcohol did you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor. servings

K. Demographics Remember: If you are answering this survey on behalf of the person listed in A1, please answer all questions about that person, not yourself. K1. Do you consider yourself to be Hispanic or Latino? Hispanic or Latino Not Hispanic or Latino K2. What race do you consider yourself to be? Mark all that apply. American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White K3. What is the highest level of education you have completed? Mark one. Less than a high school diploma High school diploma or GED Some college, Technical/Vocational School, or Associate’s Degree Bachelor’s degree (4 years of college) or higher

In case we need to get in touch with you, please provide the following contact information. If you filled this survey out on behalf of the person named in A1, the following information is about you. K4. Please provide your phone number(s) and email address: Home Phone Number: - - None Cell Phone Number: - - None E-Mail address: ______________________________ None

K5. Please provide the contact information of a friend or family member who will always know your whereabouts in case we need to contact you in the future. First Name: _________________________ Last Name: _________________________ Street Address: ________________________ _____________________________________ _____________________________________ Apartment Number: _______ City: _____________________ State: __________________ Zip code: _ _ _ _ _ Family/Friend Home Phone Number: - - None Family/Friend Cell Phone Number: - - None K6. What is this person’s relationship to you? Spouse Parent Child Brother/Sister Friend Other-specify: ____________________ Thank you for completing this questionnaire. Please make sure that you: Read and sign the Informed Consent Form, and Mail your completed booklet in the envelope provided.