Baseline - demographics - Chinese

Green Housing Study Form Approved

Appendix D3 Baseline Questionnaire Demographics OMB No. 0920-XXX

Household ID #___________

Green Housing Study

綠色住房研究

Baseline Questionnaire (Demographics)

基礎問卷（人口情況）

Public reporting burden of this collection of information is estimated to average 5 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).

這個數據收集所造成的回答負擔大約在5分鐘左右，其中包括閲讀指示，搜索現有信息庫，集合和保持所需數據，以及完成並檢查收集的數據。任何單位不能進行或贊助，任何人也沒有必要回答沒有國家管理和經費預算辦公室（OMB）批復編號的數據收集問卷。如有關回答負擔的評論或者建議請發送到美國疾病控制與方中心(CDC/ATSDR)信息收集審查辦公室：1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

Interviewer Initials _______ Date: ___________

訪問員名字： 日期：

Demographics 人口情況

1. What is/are the language/s spoken at home?

1. English and Spanish, but mostly English

2. English and Spanish, but mostly Spanish

3. Only English

4. Only Spanish

5. Other (Specify) _____________________________

1．家裏用的語言是什麽？

1．英語和西班牙語，大多是英語

2．英語和西班牙語，大多是西班牙語

3．只有英語

4．只有西班牙語

5．其它（請説明）

2. Are you Hispanic or Latino? Yes No

2．你是西班牙或者拉丁人嗎？ 是 否

3. Which one or more of the following would you say is your race?

(Select one or more)

3.1 White

3.2 Black or African American

3.3 Asian

3.4 Native Hawaiian or Other Pacific Islander

3.5 American Indian or Alaska Native

3．你認爲你是以下的哪种種族呢？（選擇一個）

3.1 白人

3.2 黑人或美洲非裔

3.3 亞洲人

3.4 夏威夷土著或其它太平洋島國土著

3.5 美洲印第安人或者阿拉斯加土著

4. How many children do you have (including the index child)? _______

4．你有幾個小孩 （包括參加研究的）？________

5. Are you…? (Circle all that apply)

5.1 Married

5.2. Divorced

5.3. Widowed

5.4. Separated

5.5. Never married

5.6. A member of an unmarried couple

5．你現在是….

5.1 已婚

5.2 離婚

5.3 守寡

5.4 分居

5.5 從沒結婚

5.6 沒有結婚的伴侶

6. Where were you born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

6．你出生在哪裏？

1．美國本土？

2．波多黎各

3．墨西哥

4．其它（請説明國家）

7. Where was your mother born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

5. DK

7．你母親出生在哪裏？

1．美國本土？

2．波多黎各

3．墨西哥

4．其它（請説明國家）

5．不知道

8. Where was your father born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

5. DK

8．你父親在哪裏 出生？

1．美國本土？

2．波多黎各

3．墨西哥

4．其它（請説明國家）

5．不知道

Education and employment

教育背景和工作情況

9. What is the highest degree or level of school you have completed?

1. Less than high school diploma, no GED

2. High school diploma or GED

3. Some college but no degree

4. Associate degree

5. Bachelor’s degree (for example, BA,BS)

6. Post graduate degree (for example, masters or doctoral)

7. Refused

8. Don’t know

9．你完成的最高學歷是什麽？

1．高中沒有畢業，沒有高中結業証

2．高中畢業，或者有高中結業証

3．讀過大學但沒有畢業

4．副學士學位

5．學士學位

6．至少碩士或者博士學位

7．不願回答

8．不知道

10. Which category represents the total combined income of all members of this FAMILY during the past 12 months?
This includes money from jobs, net income from business, farm or rent, pensions, dividends, interest, social security payments and any other money income received (by members of this FAMILY who are 15 years of age or older.)

 Less than $5,000  15,000 to 19,999  40,000 to 49,999

 5,000 to 7,499  20,000 to 24,999  50,000 to 59,999

 7,500 to 9,999  25,000 to 29,999  60,000 to 75,999

 10,000 to 12,499  30,000 to 34,999  75,000 or more

 12,500 to 14,999  35,000 to 39,999

10．以下哪一項代表你全家全體成員在過去12個月裏的縂收入？ 這包括工作的收入，生意上的收入，農場或房屋出租，退休金，股息/分紅，利息，社會保障和其它收到的經費（15嵗以上的家庭成員收到的）。

11. How many household members are supported by your total combined family income?

(Enter No. of people) _____

11.1 How many of those people are children? (Please include anyone under 18 years or anyone older than 18 years and in high school)

(Enter No. of children) _____

11．你家裏的縂收入要支持幾個家庭成員？ 家庭成員數量________

11.1 這其中有幾個是兒童？ （包括所有18嵗以下的或者18嵗以上但是還在高中的）

兒童數量______

12. Are you currently employed outside of the home? Y N

If YES, then are you exposed to these things in your job?

(Please circle all that apply)

12.1 Gasoline

12.2 Bug or insect spray

12.3 Paint thinner, brush cleaner, or furniture stripper

12.4 Varnish, lacquer, wood stain, or wet paint

12.5 Solid toilet bowl deodorants

12.6 Air freshener/ room deodorizer

12.7 Mothballs

12.8 Fingernail polish or remover

12.9 Laboratory mice or rats

12.10 Motor vehicle exhaust (e.g., bus driver, toll booth collector, etc.)

12.11 Other chemicals

12.12 None of the above

12. 你在家裏以外的地方工作嗎？ 是 否

如果是，你在工作的時候會接觸到以下的事物嗎？（選擇所有適用的）

12.1 汽油

12.2 殺蟲噴霧

12.3 油漆稀釋劑，刷子清潔劑，家具漆

12.4 油漆，噴漆，木漆，溼漆

12.5 固體的廁所除臭劑

12.6 空氣清新劑/房屋除臭劑

12.7 樟腦丸

12.8 指甲油或洗甲水

12.9 實驗室白鼠或者老鼠

12.10 汽車尾氣/排煙

12.11 其他化學物

12.12 都沒有