Time / Activity - Caregiver

Green Housing Study Form Approved

OMB No. 0920-XXXX

Appendix D11 - Time/ Activity (Mother/ Primary Caregiver)

Household ID # ______________

Green Housing Study

Time /Activity Questionnaire

(Mother/ Primary Caregiver)

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: ___________

1. Observation point (Circle One):

1. Baseline

2. Baseline part 2

3. 6-month follow-up (post-remediation)

4. 12-month follow-up (post-remediation)

2. In the days that we were sampling your air inside your home, where were you during most of the daytime (6am-6pm)?

(If evenly divided between two or more locations, please circle all that apply)

Day 1: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (outdoor job, recreation, or other activities)

Day 2: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (outdoor job, recreation, or other activities)

Day 3: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Outdoors (outdoor job, recreation, or other activities)

Day 4: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (outdoor job, recreation, or other activities)

Day 5: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (outdoor job, recreation, or other activities)

3. In the days that we were sampling your air inside your home, where were you during most of the nighttime (6pm-6am)?

(If evenly divided between two or more locations, please circle all that apply)

Day 1: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Other

Day 2: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Other

Day 3: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Other

Day 4: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Other

Day 5: a. Inside this home

2. Inside a building at work or school or other location

3. In transit (bus, car, subway, truck)

4. Other

4. In the days that we were sampling your air inside your home, 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

If “NEVER” then skip to question 5

4b. When cooking, did you use any of the following?

1. Range hood/ Exhaust fan Y N n/a

2. Opened windows or doors Y N

5. In the days that we were sampling your air inside your home, on average how many hours per day were windows open or window fan running?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

6. In the days that we were sampling your air inside your home, on average how many hours per day was the air conditioning on?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

7. In the days that we were sampling the air inside your home, on average how many hours per day was the heat on?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

If Question 7 > 1 (heat was on), then ask:

Which types did you use?

(circle ALL that apply)

1. Radiator

2. Baseboard

3. Forced hot air (vents)

4. Electric space heater

5. Kerosene space heater

6. Other type of space heater

7. Open oven

8. Fireplace/wood-burning stove

9. Other

8. In the days that we were sampling your air inside your home, on average how many hours per day was someone smoking inside the home?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

9. In the days that we were sampling your air inside your home, on average how many hours per day did you smell tobacco smoke in your home coming from other apartments?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

10. In the days that we were sampling your air inside your home, on average how many hours per day was someone burning candles or incense in the home?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

11. In the days that we were sampling your air inside your home, on average how many hours per day was someone using an air cleaner/purifier unit (like an air filter - not air freshener) inside the home?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

12. In the days that we were sampling your air inside your home, on average how many hours per day was someone using an air freshener inside the home?

1. Never

2. Less than 1 hour/day

3. 1-3 hour/day

4. Over 3 hours a day

13. In the days that we were sampling your air inside your home, on how many days did someone using spray cleaning products inside the home?

Note: These answers are different than those above.

1. Never

2. Once

3. A few times

4. Every day

13. Comments (If anything else could have influenced air sampling):

______________________________________________________________________

______________________________________________________________________

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