Baseline Questionnaire (Demographics)

Green Housing Study Form Approved

OMB No. 0920-XXXX

Appendix D3 Baseline (Mother/ Primary Caregiver)

Mother/ Primary caregiver ID# ______________

Household ID# _____________

Green Housing Study

Baseline Questionnaire (Demographics)

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).

Interviewer Initials _______ Date: ___________

Demographics

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) _____________________________

2. Are you Hispanic or Latino? Yes No

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

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

5. Are you…? (Circle all that apply)

6.1 Married

6.2. Divorced

6.3. Widowed

6.4. Separated

6.5. Never married

6.6. A member of an unmarried couple

6. Where were you born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

7. Where was your mother born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

5. DK

8. Where was your father born?

1. Mainland USA

2. Puerto Rico

3. Mexico

4. Other (Specify country) _____________________

5. DK

Education and employment

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

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

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) _____

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

2

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