Health Survey

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

Attachment C Marine Health Survey April 2011

Health Survey

OMB: 0923-0042

Document [docx]
Download: docx | pdf

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


Shape1 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

Shape2 Brother/Sister

Parent

Shape3 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


Shape5 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?

Shape6

Shape8 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?

Shape9

Shape11 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?

Shape12

Shape13 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

Shape15

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?

Shape17 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?

Shape19 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


Shape20 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.


Shape21 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.


Shape23 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?


Shape25 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?


Shape27 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?


Shape29 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)?


Shape31 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?


Shape33 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?


Shape35 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?


Shape37 Yes

No GO TO D26 on next page



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


Shape39 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.


Shape42 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?


Shape43 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?


Shape46 Yes

No GO TO F3



F2. How old were you when this was first

diagnosed?

years old



F3. Have you ever been pregnant?

Shape48 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?

Shape50 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





Shape51 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?

Shape52

Live birth of single child

Shape53 Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape55 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?

Shape57 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?

Shape59 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?


Shape61 Live birth of single child

Shape62 Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape64 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?

Shape66 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?

Shape68 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

Shape70 pregnancy?

Live birth of single child

Shape71 Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape73 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?

Shape76 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?

Shape77 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?


Shape79 Live birth of single child

Shape80 Live birth of multiple children

Tubal pregnancy

Elective abortion

Shape82 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?


Shape84 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

Shape86 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)?


Shape87 Yes

No GO TO Section H, Service in

Vietnam, on page XX


G


O TO Job #1 in next column

JShape89 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?

Shape90 Yes, at Camp Lejeune

Shape91 Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton GO TO G5


G4. Please specify the area on base

Shape93 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?

Shape94 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)?

Shape96 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?

Shape98 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?

Shape101 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?

Shape103 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?

Shape105 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?


Shape106 Yes, at Camp Lejeune

Shape108 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?

Shape109 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)?

Shape111 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?

Shape113 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?

Shape115 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?

Shape117 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?


Shape119 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?

Shape121 Yes, at Camp Lejeune

Shape123 Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton GO TO G33

G32. Please specify the area on base

Shape124 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?

Shape125 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)?

Shape127 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?

Shape129 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?

Shape131 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?

Shape133 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?


Shape135 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?

Shape137 Yes, at Camp Lejeune

Shape139 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

Shape140 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?

Shape141 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)?

Shape143 Yes

No GO TO G55


  1. 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?

Shape145 Yes

No GO TO G56


  1. 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?

Shape147 Yes

No GO TO G57


  1. 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?

Shape149 Yes

No GO TO G58 in next

column


  1. 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??

Shape151 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?

Shape153 Yes, at Camp Lejeune

Shape155 Yes, at Camp Pendleton

No, not at Camp Lejeune or Camp

Pendleton GO TO G61

G60. Please specify the area on base

Shape156 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?

Shape157 Yes

No GO TO G68


  1. 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)?

Shape159 Yes

No GO TO G69



  1. 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?

Shape161 Yes

No GO TO G70 in next

column


  1. 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?

Shape163 Yes

No GO TO G71



  1. 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?

Shape165 Yes

No GO TO G72


  1. 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?

Shape167 Yes

No GO TO Section H, Service in

Vietnam, on next page












GO TO next page




OTHER JOBS

Shape169

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?

Shape170 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)?

Shape172 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?

Shape174 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?

Shape176 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?

Shape178 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?


Shape180 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?


Shape182 Yes

Shape184 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?


Shape186 Yes

No GO TO I8 on next page



I2. Do you smoke cigarettes now?


Shape188 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.)?

Shape189 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?


Shape192 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?


Shape193 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?


Shape195 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?


Shape197 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




Shape198 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.

















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

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