6 and 12 month Follow-up - Environment

Green Housing Study ID# ______________

6-month Follow-up (Environment)

House ID# _____________

Green Housing Study

6 and 12-month Follow-up Questionnaire

(Environment)

Public reporting burden of this collection of information is estimated to average 10 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 during the previous visit, 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.

Interviewer Initials _______ Date: ___________

Observation point (Circle One):

1. 6-months follow-up (post-remediation)

2. 12-month follow-up (post-remediation)

Contact Information

Telephone numbers: Same New

Home ( ) ______________ ( ) ( )

Work ( ) ______________ ( ) ( )

Cellular ( ) ______________ ( ) ( )

Email address __________________ ( ) ( )

Alternate Contacts

Telephone numbers: Same New Relationship to respondent

Home ( ) ______________ ( ) ( ) ____________________

Work ( ) ______________ ( ) ( ) ____________________

Cellular ( ) ______________ ( ) ( ) ____________________

Email address __________________ ( ) ( ) ____________________

Environment

1. 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)

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

Y N

If YES, circle ALL that apply:

2.1 Added fabric-covered furniture

2.2 Removed fabric-covered furniture

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

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

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

3. Have you added or removed any mattresses in your home in the past 6 months?

Y N

If YES, circle ALL that apply:

3.1 Added child’s mattress

3.2 Removed child’s mattress

3.3 Added mother/primary caregiver’s mattress

3.4 Removed mother/primary caregiver’s mattress

(Note: replacing mattress means that both options for a mattress should be circled)

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

5. 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)

5.1 Cat ______

5.2 Dog ______

5.3 Bird ______

5.4 Other

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

1. Never

2. Monthly

3. Weekly

4. Daily

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

1. Never

2. Monthly

3. Weekly

4. Daily

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

1. Never

2. Monthly

3. Weekly

4. Daily

9. 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

10. 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)

11. 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

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

13. 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

14. During the last 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)

14.1 Kitchen Yes No Don’t Know

14.2 Bathroom Yes No Don’t Know

14.3 Bedroom(s) Yes No Don’t Know

14.4 Living Room Yes No Don’t Know

14.5 Basement Yes No Don’t Know N/A

14.6 Attic Yes No Don’t Know N/A

15. During the past 6 months, have you seen mold in your home? Y N DK

If YES, then ask

1. Was the area larger than a sheet of paper? Y N DK

(show paper, size 8 ½ x 11 inches)

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

17. Do you use a dehumidifier? Y N

If YES, then ask

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

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

19. 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

20. 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

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

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

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

21.2 Ozone generator

21.3 Filter

21.4 Other

Smoking

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

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

Y N DK

If YES, then ask

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

1. Indoors

2. Outdoors

3. Both

4. Don’t Know

23.2 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

23.3 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

Occupational and Other Exposures

24. 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)

24.1 Gasoline or had it on your skin?

24.2 Bug or insect spray or had it on your skin?

24.3 Paint thinner, brush cleaner, or furniture stripper

24.4 Varnish, lacquer, wood stain, or wet paint

24.5 Solid toilet bowl deodorants

24.6 Air freshener/ room deodorizer

24.7 Mothballs or had it on your skin?

24.8 Fingernail polish or remover

24.9 Laboratory mice or rats

24.10 Motor vehicle exhaust

24.11 Other chemicals

24.12 None of the above

25. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from gasoline or had it on your skin?

1. Yes

2. No

3. Don’t know

26. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from bug or insect spray or had it on your skin?

1. Yes

2. No

3. Don’t know

27. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from Paint thinner, brush cleaner, or furniture stripper or had it on your skin?

1. Yes

2. No

3. Don’t know

28. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from varnish, lacquer, wood stain, or wet paint or had it on your skin?

1. Yes

2. No

3. Don’t know

29. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from solid toilet bowl deodorants or had it on your skin?

1. Yes

2. No

3. Don’t know

30. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from air freshener/ room deodorizer or had it on your skin?

1. Yes

2. No

3. Don’t know

31. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from mothballs or had it on your skin?

1. Yes

2. No

3. Don’t know

32. In the last 3 days: today or yesterday or the day before yesterday, have you either breathed fumes from fingernail polish or remover or had it on your skin?

1. Yes

2. No

3. Don’t know

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1/31/2021