Baseline (Home Characteristics)

Green Housing Study Form Approved

OMB No. 0920-XXXX

Appendix D1 Home Characteristics Survey Mother/ primary caregiver ID# ______________

Household ID# _____________

Green Housing Study

Baseline Questionnaire (Home Characteristics)

Public reporting burden of this collection of information is estimated to average 15 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 this 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Before administering this questionnaire, identify a memorable event that occurred about 6 months ago for the participant to use as a reference point for questions regarding the time frame between the current visit and the previous visit. This event should not be recorded for this study, only used for administering this questionnaire.

1. DATE OF INTERVIEW _____ /_____ /_____ (mm/dd/yyyy)

2. INTERVIEWER INITIALS (max 3) _____ _____ _____

3. Building description (circle one)

1. A one-family house detached from other house

2. A one-family house attached to one or more houses

3. A building with two apartments (or a 2-family house)

4. A building with three or more apartments

5. Other (Specify) ______________________________________

4. Total number of floors/ stories (not including basement) ___________

4.1. Is there a basement in this building? Y N DK

4.2. On what floor/story is mother/primary caregiver’s bedroom located?

____________

(if basement, then insert -1)

4.3. On what floor/story is [Name of child with asthma Age 7-12 years] bedroom located?

____________

(if basement, then insert -1)

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Items above to be pre-filled by interviewer

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5. In total, how many people live in your household? ______

Please specify how many are:

1. Children under age 18 ________

2. Adults (≥ 18 years) ________

6. When did you move into this home? ___________ (yyyy)

If moved here within the past 12 months, then ask:

6.1 What month did you move in? ______ (mm)

7. Currently, do you have any pets in your home? Y N

If NO, then skip to next question

If YES specify the number of each type of pet(s)

1. Cat ______

2. Dog ______

3. Bird ______

4. Other (i.e.: fish, reptile, gerbil, hamster, etc.)

8. During the past 6 months, how often have you seen cockroaches in your home?

1. Never

2. Monthly

3. Weekly

4. Daily

9. During the past 6 months, how often have you seen mice in your home?

1. Never

2. Monthly

3. Weekly

4. Daily

10. During the past 6 months, how often have you seen rats in your home?

1. Never

2. Monthly

3. Weekly

4. Daily

11. During the past 6 months, have you or an exterminator used any pest control measures (pesticides, traps, etc.) to control cockroaches in your home?

Y N

If YES, circle ALL that apply

1. Sticky traps

2. Bait traps (e.g., Combat)

3. Boric acid

4. Gel

5. Spray

6. Exclusion (sealing of cracks, holes, etc.)

7. Chinese Chalk, Tres Pasitos, or Tempo

8. Other

12. During the past 6 months, have you or an exterminator used any pest control measures (pesticides, traps, etc.) to control mice and/or rats in your home?

Y N

If YES, circle ALL that apply

1. Chemical poison (to be consumed)

2. Sticky traps

3. Snap traps

4. Physical exclusion (e.g., filling holes)

13. During the past 6 months, have you or an exterminator used any pest control measures to control other insects (e.g., ants, silverfish, spiders) in your home?

Y N

If YES, circle ALL that apply

Sticky traps

1. Bait traps (e.g., Combat)

2. Boric acid

3. Gel

4. Spray

5. Exclusion (sealing of cracks, holes, etc.)

6. Chinese Chalk, Tres Pasitos, or Tempo

7. Other

14. Was the kitchen floor mopped in the past 3 days? Y N

15. During the past 6 months, which of these methods has been used to clean the floors of your home? Circle ALL that apply

1. Broom

2. Dust mop or dry mop

3. Damp mop (no water poured on floor)

4. Wet mop (involves pouring water on floor)

5. Vacuum

6. None

16. During the past 6 months, has there been water damage to your home?

(Ceilings, floors or walls or dampness from leaks, broken pipes, heavy rain or floods etc)

(Circle answers)

1. Kitchen Yes No Don’t Know

2. Bathroom Yes No Don’t Know

3. Bedroom(s) Yes No Don’t Know

4. Living Room Yes No Don’t Know

5. Basement Yes No Don’t Know N/A

6. Attic Yes No Don’t Know N/A

17. During the past 6 months, have you smelled any mold, mildew, or musty odor in your home?

Yes No DK

18. During the past 6 months, have you seen any mold in your home? Yes No DK

If YES, then ask

1. Was the area larger than a sheet of paper? Yes No DK

(show paper, size 8 ½ x 11 inches)

19. During the winter, do you add moisture to the air in your home? Y N

If YES, What method do you use? (Circle ALL that apply)

1. Cool mist humidifier

2. Hot mist humidifier (vaporizer)

3. Pans of water on radiators

4. Boiling water on stove

5. Other

20. What kind of air conditioner do you use?

(Circle ALL that apply)

1. Central unit

2. Window or Portable/free-standing unit

3. Swamp cooler/evaporative cooler

4. n/a

21. Do you use a dehumidifier? Y N

If YES, then ask

21.1 Have you used a dehumidifier in the past 6 months? Y N DK

22. Does your home have exhaust fans in the bathroom(s)? Y N DK

If YES, then ask

22.1 In the bathroom where you shower or bathe, does the exhaust fan work? Y N DK

If YES, then ask

22.1.1 How frequently do you use it when showering or bathing?

1. Never

2. Sometimes

3. All the time

23. During the winter, what is the primary way your home is heated? (Circle one answer)

1. Radiators

2. Baseboard heater

3. Electric space heater

4. Forced hot air (vents)

5. Open oven

6. Kerosene space heater

7. Fireplace/wood-burning stove

8. Other

24. In addition to the main source of heat, do you use any other source? Y N

If YES, circle ALL that apply

1. Electric space heater

2. Kerosene space heater

3. Other type of space heater

4. Open oven

5. Fireplace/wood-burning stove

6. Other

25. During the winter, how comfortable is the temperature in your home?

1. About right

2. Too hot

3. Too cold

26. During the past 6 months on average how many hours per day has the stove or oven been in use for cooking?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

27. What type of stove do you have?

1. Gas

2. Electric

3. n/a

28. Do visitors to your home ever smoke in your home? Y N DK

29. Currently, do you or others in your household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?

Y N DK

If YES, then ask

29.1. Do those who smoke usually smoke indoors, outdoors, or both indoors and outdoors?

1. Indoors

2. Outdoors

3. Both

4. Don’t Know

29.2 How often are cigarettes smoked inside the home?

a. Less than once a day

b. 1-3 Times a day

c. 4-10 Times a day

d. More than 10 Times a day

e. Don’t smoke inside the house

f. Don’t know

29.3 How often are cigars, pipes or other types of tobacco products smoked inside the home?

a. Less than once a day

b. 1-3 Times a day

c. 4-10 Times a day

d. More than 10 Times a day

e. Don’t smoke inside the house

f. Don’t know

30. Is an air cleaner or purifier regularly used inside your home? Y N DK

If YES, what type is it? (Circle ALL that apply)

1. Ionizer (e.g., Ionic Breeze or similar device)

2. Ozone generator

3. Filter

4. Other

31. Have you changed any carpeting (including rugs) in your home in the past 6 months?

Y N N/A

If YES, circle ALL that apply:

1. Added carpet/ rug

2. Removed carpet/rug

(Note: replacing carpeting means that both options should be circled)

32. Have you added/removed any piece of furniture in your home in the past 6 months?

Y N

If YES, circle ALL that apply:

1. Added fabric-covered furniture

2. Removed fabric-covered furniture

3. Added wood (e.g, solid wood, particle board) furniture

4. Removed wood (e.g, solid wood, particle board) furniture

33. Have you added or removed any mattresses in the past 6 months ? Y N

If YES, please specify:

1. [Child’s name] mattress? Y N N/A

2. Mother/ primary caregiver’s mattress? Y N N/A

34. Have you painted any rooms in your home in the past 6 months ? Y N

2

DK = Don’t know R = Refused NA = Not applicable