Michigan Biomonitoring Questionnaire

Attachment 4d

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

Biomonitoring of Persistent Toxic Substances

in Michigan Urban Fisheaters

Biomonitoring Questionnaire

Readability has been calculated using the Fry Readability Formula for determining grade level at the 6^th grade level when sentences containing agency names are omitted.

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Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

SURVEY QUESTIONNAIRE

Date of Interview:___________________________

Interviewer Name:__________________________

Introductory Script: Hello. My name is _________________. Thank you for agreeing to be part of this study. I am going to ask you some questions about you and your normal activities…things like your age, where you live, foods you eat, and a few questions about your lifestyle. Everyone in the study will be asked the same questions.

It will take about one hour to go through all of the questions.

Before we start, I want to remind you about a few things:

First, tell me if I’m going too fast or if you would like to take a break. Also, you don’t have to answer any questions that you don’t want to. Just tell me that you “don’t want to answer” and we’ll skip the question.

Second, if you are not sure about an answer, do the best you can. If you can’t remember or don’t know, just tell me “I don’t know”.

Third, please do the best you can, because your answers are very important. They will help us learn how people have come into contact with chemicals in the environment.

Finally, you can tell me to stop if you don’t want to finish answering these questions.

Do you have any questions for me?

Okay, let’s get started.

Public reporting burden of this collection of information is estimated to average 54 minutes per response for total participation, 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 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 Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

Note to interviewer: The text in italics are instructions or supporting information. Do not read aloud.

Contact Information

Script: We need some information about how to reach you so we can send you the results of the tests done on your blood and urine. All the information you give in this first part will be stored separately from the rest of the things you tell me.

1. What is your full name?

First: ______________________________

Middle initial:_______________________

Last:_______________________________

2. Do you have an email address? We will only use this to contact you if we have trouble mailing your results to you.

[ ] Yes

[ ] No (If checked, SKIP to Q 4)

[ ] DK

[ ] Refused

3. (If YES) What is it?________________________________

4. Do you have a phone number where we can reach you? This can even be the phone number of a friend, relative, or someone who will know how to find you.

[ ] Yes

[ ] No (If checked, SKIP to Q 6)

[ ] DK

[ ] Refused

5. (if YES) What is it? Phone:_______________________________  Home  Work  Cell

Phone:_______________________________  Home  Work  Cell

Phone:_______________________________  Home  Work  Cell

Alternate Phone:_______________________________  Home  Work  Cell

(friend, relative)

6. What is your street address?

Street Number: _ _____ Street Name:__ _________________ Unit: _ _________

City: _______________ __________ State: _______ ZIP Code: ______________

[ ] None

[ ] DK
[ ] Refused

7. Is your mailing address different from your street address?

[ ] Yes

[ ] No (If checked, SKIP to Q 9)

[ ] DK

[ ] Refused

8. (if YES) What is your mailing address?

P.O. Box: _________________________ or

Street Number: _ _____ Street Name:__ _________________ Unit: _ _________

City: ______________________State: _______ ZIP Code: ______________

[ ] DK

[ ] Refused

9. Indicate whether the person is a male or female. If unsure, ask his/her gender.

M F

10. What is your birthdate?

dd / mm / yyyy

[ ] DK

[ ] Refused

10a. Confirm: So that would make you [XX] years old.

11. Do you consider yourself to be Hispanic or Latino?
    
    

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

12. What race or races do you consider yourself? CHECK all that apply.

[ ] White
[ ] Black or African American
[ ] Asian
[ ] Native Hawaiian or Other Pacific Islander
[ ] American Indian or Alaska Native
[ ] DK
[ ] Refused

Separate portion above from rest of interview questionnaire

RESIDENTIAL HISTORY

Script: Next, I will ask a few questions about where you have lived.

13. How long have you lived at your current address?
    

_____ years _____ months

If ENTIRE LIFE, enter age in years

If less than 1 year, enter 00 years and number of months reported.

If full years reported, enter number of years and 00 months.

14. How long have you lived in {Saginaw AOC/Detroit AOC}? SHOW MAP
    
    

_____ years _____ months

If ENTIRE LIFE, enter age in years

If less than 1 year, enter 00 years and number of months reported.

If full years reported, enter number of years and 00 months.

current home

Script: I'd like to ask you a few questions about where you live now.

15. When was this home built?

[ ] 1978 or newer

[ ] Between 1960 and 1977

[ ] Before 1960

[ ] DK

[ ] Refused

16. Have you ever been told that your current home has lead paint?

[ ] Yes

[ ] No (If checked, SKIP to Q 18)

[ ] DK

[ ] Refused

17. (if YES) Was the lead paint removed from your home?

[ ] Yes, by the residents

[ ] Yes, by a professional

[ ] No

[ ] DK

[ ] Refused

18. In the past 7 days, were any chemical fertilizers used in your lawn or garden?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

19. Does the water used for drinking and cooking in your home come from a public water supply, a private well, or something else? (May choose more than one)

[ ] Public Water Supply

[ ] Private Well

[ ] Something Else
[ ] DK

[ ] Refused

20. Have you ever had your drinking water tested for lead or arsenic?

[ ] Yes

[ ] No (If checked, SKIP to Q 22)

[ ] DK

[ ] Refused

21. (if YES) Did the test show that you had lead or arsenic in your water?

[ ] Yes, lead

[ ] Yes, arsenic

[ ] Yes, lead and arsenic

[ ] No

[ ] DK

[ ] Refused

EDUCATION & OCCUPATION

22. What is the highest grade, level of school, or degree you have completed? SHOW CARD, if necessary.

[ ] 8^th grade or less
[ ] 9^th to 12^th grade, no diploma
[ ] High school graduate or GED
[ ] Some college, no diploma
[ ] Associate Degree
[ ] Bachelors Degree
[ ] Postgraduate, Professional, or Doctoral Degree

Script: I want to know what type of work you’ve done and the kind of business where you worked in the last 12 months.

23. What best describes your job status in the past 12 months? (If status changed within the past 12 months, enter current category)

[ ] Employed and not a student
[ ] Employed and a student
[ ] A student and not employed

[ ] Looking for work

[ ] Homemaker

[ ] Retired

[ ] Unable to Work
[ ] Refused

23. Currently, what is your job or job title and the kind of business or organization where you work?

Job 1 _____________________________________ Industry 1 _______________________________________

23. What are your usual activities or duties?

__________________________________________________________________________________________

23. If you had more than one job in the past 12 months, tell me about each.

Job 2 _____________________________________ Industry 2 _______________________________________

What {are/were} your usual activities or duties?
________________________________________________________________________________

Job 3 _____________________________________ Industry 3 _______________________________________

What {are/were} your usual activities or duties?

________________________________________________________________________________

Job 4 _____________________________________ Industry 4 _______________________________________

What {are/were} your usual activities or duties?

________________________________________________________________________________

Script: Now I will ask you about jobs you have held where you have come into contact with chemicals. Be sure to include seasonal work, self-employment, military service, and farm work in your answers.

WORK HISTORY
As part of a job, have you ever… CHECK response	(if YES) What {is/was} your job title/description?	(if YES) Year started job	(if YES) Year ended job
Have you ever applied pesticides that kill insects, fungus, or weeds? [ ] Yes [ ] No [ ] DK [ ] Refused	27a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	27b ________year	27c ________year
Have you ever worked for a trash or recycling company? [ ] Yes [ ] No [ ] DK [ ] Refused	28a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	28b ________year	28c ________year
Have you ever worked in a foundry, a smelter, a welding facility or steel mill? [ ] Yes [ ] No [ ] DK [ ] Refused	29a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	29b ________year	29c ________year
Have you ever removed lead paint? [ ] Yes [ ] No [ ] DK [ ] Refused	30a Job title/description ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________ __________________________________________________	30b ________year	30c ________year

Have you ever worked with commercial electrical equipment such as transformers, or capacitors or worked for an electric power company? [ ] Yes [ ] No [ ] DK [ ] Refused	31a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	31b ________year	31c ________year
Have you ever been a maintenance worker in any type of heavy industry? [ ] Yes [ ] No [ ] DK [ ] Refused	32a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	32b ________year	32c ________year
Have you ever worked for a battery manufacturing or recycling company? [ ] Yes [ ] No [ ] DK [ ] Refused	33a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	33b ________year	33c ________year
Have you ever worked for a chemical manufacturing company? [ ] Yes [ ] No [ ] DK [ ] Refused	34a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________	34b ________year	34c ________year

Have you ever worked for an automobile manufacturing company? [ ] Yes [ ] No [ ] DK [ ] Refused

35a Job title/description __________________________________________________ ­­­­­­­­­­­­­­­­__________________________________________________ __________________________________________________

35b ________year

35c ________year

LIFESTYLE

Script: We also want to know about a few lifestyle choices that might increase or decrease the amount of chemicals in your body.

23. Most days, do you take any dietary supplements that have fish oil or other Omega 3 oil?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

23. Most days, do you take any store-bought herbal supplements?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

23. Have you smoked at least 100 cigarettes (5 packs) in your lifetime?

[ ] Yes

[ ] No (if checked, SKIP to Q 44)

[ ] DK

[ ] Refused

23. (If YES) Do you smoke cigarettes now?

[ ] Yes (if checked, SKIP to Q 42)

[ ] No

[ ] DK

[ ] Refused

23. (If NO) How long has it been since you last smoked cigarettes regularly? CIRCLE months or years

_____ months/years

23. (if NO) For how many {months/years} did you smoke? CIRCLE months or years

_____ months/years

23. (If YES, CURRENT SMOKER) How often do you smoke cigarettes?

[ ] Daily

[ ] Weekly (if checked, SKIP to Q 43)

[ ] Monthly (if checked, SKIP to Q 43)

[ ] DK

[ ] Refused

23. (If DAILY) How many cigarettes do you smoke per day?

Note: One pack equals 20 cigarettes

[ ] 1-5 per day

[ ] 6-10 per day

[ ] 11-20 per day

[ ] > 20 per day

[ ] DK

[ ] Refused

23. For how many {months/years} have you smoked? CIRCLE months or years
    
    _____ months/years

23. Does anyone smoke cigarettes inside your home?

[ ] Yes

[ ] No (if checked, SKIP to Q 46)

[ ] DK

[ ] Refused

23. (If YES) How often do household members or guests smoke cigarettes in your home?

[ ] Daily
[ ] Weekly
[ ] Monthly
[ ] DK
[ ] Refused

BIRTHS

(If MALE, SKIP to Q 49)

(If FEMALE, READ Script) We want to know if you ever had children, because giving birth and nursing can change the amount of some chemicals in the body.

23. How many children have you given birth to? (if none, ENTER “0” and SKIP to Q 49)

______ child/children

Birth Order (Oldest-to-Youngest)	1st	2nd	3rd	4th	5th	6th	7th	8th	9th	10th
From oldest to youngest, what year was each child born?
How many months {were your children/was your child} breastfed?

Script: The next questions are about activities or interests done as hobbies. You may do these activities for fun, to earn money, or to keep up your house.

HOBBIES AND ACTIVITIES
	In the past 12 months, have you done any of the following activities at home or somewhere else?	In the past 12 months, has someone else living in your household done any of these activities in your home?
Dyeing material (Ex: textiles, making quills)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Electronics assembly (Ex: computer circuits, radios, robot kits)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Gardening or farming	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Glass crafting (Ex: stained glass, glassblowing)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Leathercrafting (Ex: leather crafts, taxidermy, tanning hides - chemical or brain)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Metal working (Ex: enameling, jewelry making, making fishing sinkers, loading shotgun shells, casting bullets, lost wax casting)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Painting and glazing (Ex: household painting, art, ceramics making)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Printmaking (Ex: intaglio, etching, lithography)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused
Woodworking (Ex: cabinet making, carpentry, furniture making, wood turning, working with treated lumber)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes [ ] No [ ] DK [ ] Refused

23. In the past 12 months, about how many times did you swim, dive or wade in Saginaw area rivers or lakes or the Detroit River? (if none, enter “00”)

__ times

Script: Food has many health benefits, but it can also contain chemicals from the environment. In this part of the interview, I will ask you questions about fish, wild animals, home-raised, and home-grown foods that you eat.

For most of these questions, I will ask how many times you ate each food in the past 12 months. You can answer in number of times per week, per month, or in the past year. Answer each question as best you can.

FISH CONSUMPTION

Script: These questions are about the caught fish that you eat from Michigan waters. By caught fish I mean fish caught by you, a family member, or an acquaintance; not fish you bought from a store or ate in a restaurant. By Michigan waters, I mean any river or lake in Michigan, including the Great Lakes.

23. Have you eaten fish or shellfish in past week?

[ ] Yes

[ ] No (if checked, SKIP to Q 55)

[ ] DK

[ ] Refused

23. (If YES to Q 53) When was the last time you ate fish or shellfish?

[ ] Today/same day

[ ] Yesterday/1 day ago

[ ] Day before yesterday/2 days ago

[ ] 3 days ago

[ ] 4-7 days ago

[ ] DK

[ ] Refused

23. (SHOW MODEL) Compared to the {picture/mode}] of a half-pound serving of fish, would you say that a meal of fish you eat is usually

[ ] Smaller than the model
[ ] Same or about the same size as the model
[ ] More than the model
[ ] DK
[ ] Refused

23. Over your lifetime, how many years have you eaten fish of any type caught from Michigan waters? (If NEVER or LESS THAN 1 YEAR, ENTER 00)

_______ years

23. Over your lifetime, how many years have you eaten fish from the Saginaw AOC? (If NEVER or LESS THAN 1 YEAR,ENTER 00)
    
    _______ years

23. Over your lifetime, how many years have you eaten fish from the Detroit AOC? (If NEVER or LESS THAN 1 YEAR,ENTER 00)

_______ years

23. Over your lifetime, how many years have you eaten fish from the Great Lakes? (If NEVER or LESS THAN 1 YEAR,ENTER 00)

_______ years

SCRIPT: The next questions are about caught fish from Michigan waters that you have eaten at leave five times in your lifetime. (SHOW CAUGHT FISH CARD)

23. Have you eaten [SPECIES] at least five times in your life? (If YES, COMPLETE Caught Fish Eaten table. Use separate Table for each [SPECIES] consumed)

Bluegill (SunfIsh) [ ] Y [ ] N [ ] DK

Brook trout [ ] Y [ ] N [ ] DK

Brown trout [ ] Y [ ] N [ ] DK

Bullhead [ ] Y [ ] N [ ] DK

Carp [ ] Y [ ] N [ ] DK

Catfish [ ] Y [ ] N [ ] DK

Crappie (White, Black, Calico, Strawberry Bass) [ ] Y [ ] N [ ] DK

Eelpout (Burbot, Ling. Lawyer, Freshwater cod) [ ] Y [ ] N [ ] DK

Freshwater drum (Sheepshead) [ ] Y [ ] N [ ] DK

Lake herring (Cisco, Tullibee) [ ] Y [ ] N [ ] DK

Lake trout [ ] Y [ ] N [ ] DK

Largemouth bass (Black bass) [ ] Y [ ] N [ ] DK

Muskellunge (Muskie) [ ] Y [ ] N [ ] DK

Northern pike [ ] Y [ ] N [ ] DK

Rainbow smelt [ ] Y [ ] N [ ] DK

Rainbow trout (Steelhead) [ ] Y [ ] N [ ] DK

Rock bass [ ] Y [ ] N [ ] DK

Salmon [ ] Y [ ] N [ ] DK
Sucker [ ] Y [ ] N [ ] DK

Smallmouth bass (Black bass) [ ] Y [ ] N [ ] DK

Walleye [ ] Y [ ] N [ ] DK

Whitefish [ ] Y [ ] N [ ] DK

White bass (Silver bass) [ ] Y [ ] N [ ] DK

White perch [ ] Y [ ] N [ ] DK

Yellow perch [ ] Y [ ] N [ ] DK

Other, specify _____________________________

Other, specify _____________________________

Other, specify _____________________________

[ ] DK

[ ] Refused

CAUGHT FISH EATEN
USE separate Table for each [SPECIES] consumed)	(if YES) In your lifetime, have you eaten [SPECIES] that were caught from {Saginaw AOC/Detroit AOC}?	(if YES) How many years have you eaten [SPECIES] from {Saginaw AOC/Detroit AOC}? (If NEVER, ENTER 00 years)	In the past 12 months, did you eat [SPECIES] from {Saginaw AOC, Detroit AOC, or Other Location}? WRITE name of up to three lakes or rivers and counties for Other Location.	(If YES) In the past 12 months, how many times did you eat [SPECIES] from {Saginaw AOC/Detroit AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)
_________________ (Write SPECIES name)	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	___times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
	[ ] Yes, Detroit AOC [ ] No [ ] DK [ ] Refused	________ years	[ ] Yes, Detroit AOC [ ] No [ ] DK [ ] Refused	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
			[ ] Yes, Other Location Name of up to three lakes or rivers and counties where fish were caught most often: ______________________________________________ _______________________ [ ] No [ ] DK [ ] Refused	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

Script: Now I’d like to ask you how the fish, caught by you or someone you know, was prepared and cooked for your meals.

23. What parts of the fish did you usually eat in the past 12 months? (CHECK all that apply)

[ ] Fillet

[ ] Skin

[ ] Cheeks
[ ] Eggs/Roe
[ ] Liver

[ ] Other, specify _____________________

23. How was the fish that you ate in the past 12 months usually cleaned? (CHECK all that apply)
    
    [ ] Trimmed fat
    [ ] Trimmed belly meat
    [ ] Removed/punctured skin
    [ ] Removed guts/gutted
    [ ] Other, specify ______________________
    
    
    

24. How was the fish that you ate in the past 12 months usually cooked? (CHECK all that apply)
    
    [ ] Pan fry
    [ ] Deep fried
    [ ] Baked/Broiled
    [ ] Boiled/Poached
    [ ] Smoked
    [ ] Stewed/Chowder
    [ ] Dried
    [ ] Grilled
    [ ] Eaten raw
    [ ] Pickled
    [ ] Other, specify _____________________

23. For fish caught in any of these areas (SHOW MAPS), how has the total amount of fish you eat changed during the past five years?

Saginaw AOC Detroit AOC Other locations

[ ] Eat less [ ] Eat less [ ] Eat less
[ ] Eat about the same [ ] Eat about the same [ ] Eat about the same
[ ] Eat more [ ] Eat more [ ] Eat more
[ ] N/A [ ] N/A [ ] N/A

STORE / MARKET / RESTAURANT FISH

Script: The following questions are about fish you have eaten that were bought at a store, supermarket, or restaurant. (SHOW State Bought List)

FISH BOUGHT FROM A STORE, SUPERMARKET, OR RESTAURANT
SPECIES	Which fish have you eaten at least five times in your life from a store, supermarket, or restaurant? SHOW CARD	(If [SPECIES] is YES) How many years did you eat [SPECIES] from a store, supermarket or restaurant? (If NEVER, enter 00 years)	In the past 12 months, have you eaten [SPECIES] bought from a store, supermarket, or restaurant? Tell me the number of times per week, month, or year, whichever is easiest to remember. [If NEVER, enter 00 times per year)
Catfish	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Salmon	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

Trout	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Tuna (canned)	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Tuna (steak/filet, not canned)	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Whitefish	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

Group A: Cod, Haddock, Herring, Freshwater Perch, Ocean Perch, Pollock, Scallops, Shrimp, Tilapia	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Group B: Ocean Bass, Grouper, Halibut, Mackerel, Mahi Mahi, Orange Roughy, Snapper	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Group C: King Mackerel, Shark, Swordfish, Tilefish	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Other: SPECIFY ___________________	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

Other: SPECIFY ___________________	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Other: SPECIFY ___________________	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
Other: SPECIFY ___________________	[ ] Yes [ ] No [ ] DK [ ] Refused	_____ years	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

wild birds AND animals

Script: The next questions are about hunted wild birds or animals that you have eaten at least five times in your lifetime.

23. Have you eaten [SPECIES] at least five times in your life? (If YES, COMPLETE Wild Bird/Animal Eaten Table. Use separate table for each [SPECIES] consumed)

Deer (Venison) [ ] Y [ ] N [ ] DK

Duck, Goose, Coot [ ] Y [ ] N [ ] DK

Grouse, pheasant, turkey, or other upland bird [ ] Y [ ] N [ ] DK

Raccoon, rabbit, squirrel, porcupine, other small animal [ ] Y [ ] N [ ] DK

Turtle [ ] Y [ ] N [ ] DK

WILD BIRD/ANIMAL EATEN	(If YES) Have you eaten [WILD BIRD/AMINAL] at least five times in your lifetime that was/were hunted from {Saginaw AOC/Detroit AOC}? SHOW CARD.	(If YES) How many years have you eaten [WILD BIRDS/ANIMALS] from {Saginaw AOC/Detroit AOC}? (If NEVER, ENTER 00 years)	In the past 12 months, did you eat [WILD BIRD/AMINAL] that were hunted from {Saginaw AOC/Detroit AOC/Other Location}? (WRITE name of county for Other Location)	(If YES) In the past 12 months, how many times did you eat [WILD BIRD/ANIMAL] from {Saginaw AOC/Detroit AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)
________________ (Write SPECIES name)	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
	[ ] Yes, Detroit AOC [ ] No [ ] DK [ ] Refused	________ years	[ ] Yes, Detroit AOC [ ] No [ ] DK [ ] Refused	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused
			[ ] Yes, Other Location Name of counties: ______________________________________________ _______________________ [ ] No [ ] DK [ ] Refused	_ times per [ ] wk [ ] mo [ ] year [ ] DK [ ] Refused

23. In the past 12 months, what parts of the [Wild Bird or Animal] did you usually eat? (CHECK all that apply. If NONE, enter 00)

[ ] Meat

[ ] Skin

[ ] Liver

[ ] Other, specify ___________________________________________________

[ ] DK

[ ] Refused

home-raised or home-grown FOODS

Script: The next set of questions is about home-raised birds or animals and home-grown vegetables and fruit. For this interview, “home-raised” and “home-grown” means not purchased in a grocery store or market and not wild.

HOME- RAISED, HOME- GROWN FOOD EATEN
FOOD	Which of these [HOME- RAISED, HOME- GROWN FOOD] have you ever eaten at least five times in your lifetime?	(If YES) Was/were the [HOME- RAISED, HOME-GROWN FOOD] you ate raised in {Saginaw/Other Location}? (SHOW MAPS. MARK all that apply)	How many years have you eaten [HOME- RAISED, HOME-GROWN FOOD] from {Saginaw AOC/Other Location}? (If NEVER, ENTER 00 times per year)	In the past 12 months, how many meals of [HOME-RAISED, HOME-GROWN FOOD] did you eat from {Saginaw AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)
Eggs	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
		[ ] Yes, Other Location Name of counties: ____________________________________________________ [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused

Milk and other dairy products	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
		[ ] Yes, Other Location Name of counties: ____________________________________________________ [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
Poultry or poultry products (chicken, duck, goose, turkey)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
		[ ] Yes, Other Location Name of counties: ____________________________________________________ [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused

Meat and meat products (other than poultry)	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
		[ ] Yes, Other Location Name of counties: ____________________________________________________ [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
Home-grown vegetables and fruit	[ ] Yes [ ] No [ ] DK [ ] Refused	[ ] Yes, Saginaw AOC [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused
		[ ] Yes, Other Location Name of counties: ____________________________________________________ [ ] No [ ] DK [ ] Refused	________ years	_ times per [ ] wk for [ ] mo for [ ] year [ ] DK [ ] Refused

23. What parts of the home-raised poultry did you usually eat?
    
    [ ] Meat
    [ ] Skin
    [ ] Liver
    [ ] Other _______________________

23. What parts of the home-raised animals did you usually eat?
    
    [ ] Meat
    [ ] Skin
    [ ] Liver
    [ ] Kidney
    [ ] Other _______________________

DEMOGRAPHICS

Script: To help us compare results between groups of people, it is useful to know the annual income of the study participants. This information can also be useful when planning public health policies and programs. This is the final set of questions.

Script: We consider your family to include everyone currently living with you, who is related by birth, marriage, or adoption and unmarried partners.

23. Including yourself, how many family members currently live with you?

_________ number of family members

23. Can you tell me your total family income in {LAST CALENDAR YEAR} before taxes? SHOW CARD

[ ] Less than $25,000

[ ] $25,000 to less than $35,000

[ ] $35,000 to less than $50,000

[ ] $50,000 to less than $75,000

[ ] $75,000 to less than $100,000

[ ] $100,000 or more

[ ] DK

[ ] Refused

Closing Script:

Thank you for answering these questions. I know it took awhile but the information you gave me is very important to this study.

We will send you a letter with your test results at the mailing address you gave me. Most everyone will receive their letters after we get the test results from all of the people in the study. However, we will let you know as soon as possible if any of your test results are high enough that we think you should be notified right away. In that case, there may be things you want to do to protect your health.

Do you have any questions about the study or how you will get your results? If have questions after you leave, you can contact us at the number in your copy of the Consent Form.

Will you need transportation when you are done? If so, stop by the reception desk and they will help you.

If you don’t have any questions, I will show you where to find the (nurse/phlebotomist). (She/he) will get your height, weight, and blood pressure. (She/he) will also ask you whether or not you have gained or lost weight in the last year. Then (she/he) will get your blood and urine samples.

Thank you for coming in today. You can pick up your gift card at the reception desk on your way out.

Clinical Measurements

Now we’ll measure your height.

Measurement: ______ft ______ in

[ ] Refused

Next I’d like to measure your weight.

Measurement: ______lbs

[ ] Refused

Now I’d like to measure your blood pressure.

Measurement: ___ / ___

[ ] Refused

Hand Cards and Response Categories

EDUCATION LEVEL OR DEGREE

8^th Grade or less

9^th to 12^th Grade, No Diploma
High School Graduate or GED
Some College, No Diploma
Associate Degree
Bachelor Degree
Postgraduate, Professional, or Doctoral Degree

TYPES OF INCOME

Earnings Unemployment compensation Workers’ compensation Social security Supplemental security income Public assistance Veterans’ payments

Survivor benefits Disability benefits Pension or retirement income Interest Dividends Rents, royalties, and estates and trusts

Educational assistance Alimony Child support Financial assistance from outside of the household Other income

TOTAL FAMILY INCOME

Less than $25,000

$25,000 to less than $35,000

$35,000 to less than $50,000

$50,000 to less than $75,000

$75,000 to less than $100,000

$100,000 or more

Caught Fish

Bluegill (Sunfish)

Brook trout

Brown trout

Bullhead

Carp

Catfish

Chinook salmon (King salmon)

Coho salmon

Black/White crappie (Calico, Strawberry bass)

Eelpout (Burbot, Ling, Lawyer, Freshwater cod)

Freshwater drum (Sheepshead)

Lake herring (Cisco, Tullibee)

Lake trout

Largemouth bass (Black bass)

Muskellunge (Muskie)

Northern pike

Rainbow smelt

Rainbow trout (Steelhead)

Rock bass

Smallmouth bass (Black bass)

Sturgeon

Suckers

Walleye

Whitefish

White bass (Silver bass)

White perch

Yellow perch

Bought Fish

Catfish

Salmon

Trout

Tuna (canned)

Tuna (steak/fillet, not canned)

Whitefish

Group A – Cod, Haddock, Herring, Freshwater perch, Ocean perch, Pollock, Scallops, Shrimp, Tilapia

Group B – Ocean bass, Grouper, Halibut, Mackerel, Mahi Mahi, Orange Roughy, Snapper

Group C – King Mackerel, Shark, Swordfish, Tilefish

Wild Game

Deer

Duck, Goose, Coot

Grouse, pheasant, turkey or other upland bird

Raccoon, Rabbit, Squirrel, Porcupine, Other Small Animal

Turtle