New York Questionnaire
Biomonitoring of Great Lakes Populations Program
Att6f_NY_IntrvwQs_LA
New York Questionnaire
OMB: 0923-0044
Form Approved OMB
No. 0923-XXXX Exp. Date
xx/xx/20xx xxxxxx/xx/xx/20xx 
New York State Biomonitoring of the Great Lakes Populations
Interview Questionnaire for Licensed Anglers
CONTACT INFORMATION
What is your full name?
First: __________________ Last: __________________ Middle initial: ___
___ Refused
Do you have an email address?
___ Yes What is it? ________________________________________
___ No
___ Don’t know
___ Refused
Do you have a phone number where we can reach you? This can be the phone number of a friend, relative, or someone who will know how to find you.
___ Yes _____________________ Home Work Cell Other: _________
_____________________ Home Work Cell Other: _________
_____________________ Home Work Cell Other: _________
___ No
___ Don’t know
___ Refused
What is your street address?
Street Number: ______ Street Name:_____________________ Unit: ____
City: ___________________________ State: _______ ZIP Code: ________
Is your mailing address different from your street address?
___ Yes What is your mailing address?
Street Number: ______ Street Name:_____________________ Unit: ____
City: ___________________________ State: _______ ZIP Code: _______
___ No
___ Don’t know
___ Refused
Public reporting burden of
this collection of information is estimated to average 30 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).
6. If you want your blood and urine test results sent to your doctor, what is his/her name, phone number, and address?
Name of doctor: ______________________________
Telephone number: _________________
Address: _____________________________________________________________
Script (if participant does not provide physician’s name): If you do not want the results sent to your physician or you don’t have one, the results will be sent to a physician at the New York State Department of Health.
SEX AND AGE
Script. Now we will begin the interview. The first part is about your background. It will help us compare your answers to other participants’ answers.
Indicate whether the person is male or female. If unsure, ask his/her sex.
___ Male
___ Female
What is your birthdate?
____ / _____ / _______ So you are _____ years old?
mm dd yyyy
ETHNICITY AND RACE
Do you consider yourself to be Hispanic or Latino?
___ Yes
___ No
___ Don’t know
___ Refused
What race do you consider yourself to be? (Check all that apply.)
___ White
___ Black or African American
___ Asian
___ Native Hawaiian or Other Pacific Islander
___ American Indian or Alaska Native
___ Other Specify: _______________
___ Don’t know
___ Refused
RESIDENTIAL HISTORY
Script: Next, I will ask you where you have lived.
How long have you lived at your current address?
___ Entire life
(If less than 1 year, enter 0 years and number of months. If full years reported, enter number of years and 0 months.)
_____ years _____ months
When was this home built?
___ 1978 or after
___ 1950 to 1977
___ Before 1950
___ Don’t know
___ Refused
How long have you lived in these counties? SHOW MAP.
___ Entire life
(If less than 1 year, enter 0 years and number of months. If full years reported, enter number of years and 0 months.)
_____ years _____ months
Were you born in the United States?
___ Yes
___ No
___ Don’t know
___ Refused
EDUCATION AND OCCUPATION
What is the highest grade level of school or degree you have completed?
___ 8th grade or less ___ Bachelor’s degree
___ 9th to 11th grade, no diploma ___ Postgraduate, professional, or doctoral degree
___ High school graduate or GED ___ Don’t know
___ Some college, no diploma ___ Refused
___ Associate degree
Have you had a job in the past 12 months?
___ Yes go to #17
___ No go to #19
___ Don’t know go to #19
___ Refused go to #19
Script: I would like to know what type of work you’ve done and the kind of business where you worked in the past 12 months.
Currently, what is your job or job title and the kind of business or organization where you work?
Job 1. __________________________ Industry 1. ___________________________
(Optional) What are your usual activities or duties? ___________________________
______________________________________________________________________
If you had more than one job in the past 12 months, tell me about each one.
If no additional jobs, go to #19.
Job 2. __________________________ Industry 2. ___________________________
(Optional) What are your usual activities or duties? ___________________________
______________________________________________________________________
Job 3. __________________________ Industry 3. ___________________________
(Optional) What are your usual activities or duties? ___________________________
______________________________________________________________________
Job 4. __________________________ Industry 4. ___________________________
(Optional) What are your usual activities or duties? ___________________________
______________________________________________________________________
LIFESTYLE
Script: The next group of questions will be about any behaviors or customs you have that could expose you to some contaminants found in Great Lakes fish.
On most days, do you take or use any of the following? (Check all that apply.)
___ Herbal medicine or supplements Specify: _________________________________
___ Fish oil
___ None
___ Don’t know
___ Refused
Have you smoked at least 100 cigarettes (or 5 packs) in your lifetime?
___ Yes (Ever smoker) go to #21
___ No (Never smoker) go to #25
___ Don’t know go to #25
___ Refused go to #25
(Ever smoker) Do you smoke cigarettes now?
___ Yes (Current smoker) go to #23
___ No (Former smoker) go to #22
___ Don’t know go to #25
___ Refused go to #25
(Former smoker) How long has it been since you last smoked cigarettes regularly?
_____ months or _____ years go to #25
(Current smoker) How often do you smoke cigarettes?
___ Daily (Daily smoker) go to #24
___ Weekly go to #25
___ Monthly go to #25
___ Don’t know go to #25
___ Refused go to #25
(Daily smoker) How many cigarettes do you smoke per day?
(1 pack=20 cigarettes)
___ 1-5 per day
___ 6-10 per day
___ 11-20 per day (>1/2 and <1 pack per day)
___ >20 per day (>1 pack per day)
___ Don’t know
___ Refused
Do you use chewing tobacco or snuff?
___ Yes go to #26
___ No go to #27
___ Don’t know go to #27
___ Refused go to #27
How often do you use chewing tobacco or snuff?
___ Daily
___ Weekly
___ Monthly
___ Don’t know
___ Refused
PERSONAL ACTIVITIES
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.
In the past 12 months, have you or someone else in your household done any of the following activities? SHOW CARD
___ Yes go to #28
___ No go to # 30
___ Don’t know go to #30
___ Refused go to #30
Tell me which activities you did in the last 12 months.
SHOW CARD. (Check all that apply.)
___ Dyeing material ___ Metal work ___ None
___ Electronics assembly ___ Painting and glazing ___ Don’t know
___ Gardening or farming ___ Printmaking ___ Refused
___ Glass crafting ___ Woodworking
___ Leather crafting
Tell me which activities another household member has done in your home the last 12 months.
SHOW CARD. (Check all that apply.)
___ Electronics assembly ___ Painting and glazing ___ None
___ Gardening or farming ___ Printmaking ___ Don’t know
___ Glass crafting ___ Woodworking ___ Refused
___ Leather crafting
REPRODUCTIVE HISTORY
If MALE go to #34
If FEMALE go to #30
Are you pregnant?
___ Yes go to #31
___ No go to #32
___ Don’t know go to #32
___ Refused go to #32
How many weeks pregnant are you?
______ weeks
___ Don’t know go to #32
___ Refused go to #32
How many children have you given birth to?
(If NONE, enter 0 go to #34)
______ child/children
___ Don’t know go to #34
___ Refused go to #34
From oldest to youngest, what year was each child born and how many months was each child breastfed? (If a child was not breastfed, enter 0 months.)
-
Birth
order
Birth year
(yyyy)
Months
breastfed
Birth
order
Birth year
(yyyy)
Months
breastfed
1st
5th
2nd
6th
3rd
7th
4th
8th
FISH AND SHELLFISH
Have you eaten fish or shellfish in the past week?
___ Yes go to #35
___ No go to #36
___ Don’t know go to #36
___ Refused go to #36
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
___ Don’t know
___ Refused
CAUGHT FISH
Script: These questions are about the fish you eat that you caught yourself or by someone you know.
Compared to this model of a half-pound serving of fish, would you say that a typical meal of fish you eat is usually:
___ Less (smaller than the model)
___ Same or about the same
___ More (larger than the model)
___ Don’t know
___ Refused
Have you eaten fish from any of these bodies of water in New York State?
SHOW CARD AND MAPS. (Check all that apply.)
___ Lake Erie ___ Erie Canal (from Lake Erie to eastern border of Erie County only) ___ Buffalo River (including Cazenovia Creek) ___ Upper Niagara River (including shore of Lake Erie) ___ Lower Niagara River ___ Lake Ontario ___ Eighteenmile Creek ___ Creeks surrounding Eighteenmile, including Fourmile, Twelvemile, Hopkins, Bull, Keg, Golden Hill, Johnson, and Erie Canal |
___ Lower Genesee River (from Driving Park Bridge to Lake Ontario) ___ Irondequoit Bay/Creek ___ Ponds of Greece, including Little, Round, Buck, Long, Cranberry ___ Braddock Bay ___ Lake Ontario Creeks, including Yanty, Sandy, Cowsucker, Brush, East, West, Salmon, Buttonwood, Northrup (including Black), Larkin (including Smith), Slater, Shipbuilder's, Mill, and Fourmile ___ Don’t know ___ Refused |
Of the fish from these bodies of water, which have you eaten at least five times in your life? SHOW CARD.
(Check the species eaten at least 5 times.)
-
___ American eel
___ Black crappie
___ Brook trout
___ Brown bullhead
___ Brown trout
___ Chain pickerel
___ Channel catfish
___ Chinook (king) salmon
___ Coho salmon
___ Common carp
___ Freshwater drum, sheepshead
___ Goldfish
___ Lake sturgeon
___ Lake trout
___ Largemouth bass
___ Minnow
___ Northern hog sucker
___ Northern pike
___ Pink salmon
___ Quillback
___ Rainbow smelt
___ Rainbow/steelhead trout
___ Rock bass
___ Round goby
___ Smallmouth bass
___ Sunfish (blue gill, pumpkin seed)
___ Walleye
___ White (silver) bass
___ White perch
___ White sucker
___ Yellow bullhead
___ Yellow perch
___Other Specify: ___________
If one or more species checked go to #39
___ None go to #45
___ Don’t know go to #45
___ Refused go to #45
Script: I’m going to ask you about each fish species you just told me you’ve eaten at least five times.
Over your lifetime, how many years have you eaten [fish species] out of these bodies of water?
_____ years
___ Don’t know
___ Refused
In the past 12 months, how many times did you eat [fish species]? Tell me the number of times per week, month, or year, whichever is easiest to remember.
(If never, enter 0 times per year.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
What parts of [fish species] did you usually eat? SHOW CARD.
(Check all that apply.)
___ Fillet ___ Liver ___ Don’t know
___ Skin ___ Eggs/Roe ___ Refused
___ Cheek ___ Other Specify: ____________
How was the [fish species] usually cleaned? SHOW CARD.
(Check all that apply.)
___ Filleted ___ Trimmed belly meat ___ Don’t know
___ Gutted ___ Removed cheeks ___ Refused
___ Trimmed fat ___ Punctured or removed skin
How was the [fish species] usually cooked? SHOW CARD. Check all that apply.
___ Pan fried ___ Baked/broiled ___ Don’t know
___ Deep fried ___ Eaten raw ___ Refused
___ Boiled/poached ___ Smoked
___ Stew/chowder ___ Dried
___ Grilled ___ Pickled
For fish caught in any of these areas, how has the total amount of fish you eat changed during the past five years?
___ Eat less
___ Same or about the same
___ Eat more
___ Don’t know
___ Refused
WILD BIRDS AND ANIMALS
In the past 12 months, have you eaten waterfowl (such as ducks or geese) or bear that were hunted near any of the following bodies of water in New York State?
SHOW CARD AND MAPS.
(Check all that apply.)
___ Lake Erie ___ Erie Canal (from Lake Erie to eastern border of Erie County only) ___ Buffalo River (including Cazenovia Creek) ___ Upper Niagara River (including shore of Lake Erie) ___ Lower Niagara River ___ Lake Ontario ___ Eighteenmile Creek ___ Creeks surrounding Eighteenmile, including Fourmile, Twelvemile, Hopkins, Bull, Keg, Golden Hill, Johnson, and Erie Canal |
___ Lower Genesee River (from Driving Park Bridge to Lake Ontario) ___ Irondequoit Bay/Creek ___ Ponds of Greece, including Little, Round, Buck, Long, Cranberry ___ Braddock Bay ___ Lake Ontario Creeks, including Yanty, Sandy, Cowsucker, Brush, East, West, Salmon, Buttonwood, Northrup (including Black), Larkin (including Smith), Slater, Shipbuilder's, Mill, and Fourmile ___ Don’t know ___ Refused |
In the past 12 months, about how many times did you swim, dive, or wade (including wading for fishing or hunting) in any of these bodies of water? SHOW CARD AND MAPS.
(If never, enter 0 times.)
_____ times
___ Don’t know
___ Refused
In the past 12 months, have you eaten fish from any of these other bodies of water in New York State? SHOW CARD.
___ Adirondack Park Region lakes, ponds, or rivers Specify: ________________________
___ Hudson River Specify locations along the river: ________________________
___ Catskill Park Region lakes, ponds, or rivers Specify: ___________________________
___ Canadice Lake (Ontario County)
___ Other bodies of water in the sportfish advisories Specify: ______________________
_______________________________________________________________________
___ Don’t know
___ Refused
STORE BOUGHT FISH
Script: The following questions are about fish bought at a store or supermarket. Please do not include fish from restaurants.
Over your lifetime, how many years have you eaten any of these fish bought at a store or supermarket? SHOW CARD.
(If never or less than 1 year, enter 0 years.)
_____ years
___ Don’t know
___ Refused
Which of these fish that was bought at a store or supermarket have you eaten at least five times in your life? SHOW CARD.
(Check the species eaten at least 5 times.)
___ Grouper ___ Salmon (including canned)
___ Shark ___ Tuna (canned)
___ Swordfish ___ Tuna (not canned)
If ate at least one type of fish go to #50
___ None
___ Don’t know go to #52
___ Refused
How many years did you eat [fish species] bought at a store or supermarket?
_____ years
___ Don’t know
___ Refused
In the past 12 months, how many times did you eat [fish species]? Tell me the number of times per week, month, or year, whichever is easiest to remember.
(If never, enter 0 times.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
OTHER STORE BOUGHT FOODS
Script: The following questions are about typical grocery store or market foods that you may have eaten in the past 12 months. The purpose of the following four questions is to estimate if you have a high animal fat diet or low animal fat diet.
In the past 12 months, how often did you eat meals with… SHOW CARD.
Whole eggs?
(If never, enter 0 times per year.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
Whole milk products (including 2% milk)?
(If never, enter 0 times per year.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
Poultry meat?
(If never, enter 0 times per year.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
(If never, enter 0 times per year.)
___ times per (circle one) week month year
___ Don’t know
___ Refused
INCOME
Script: We want to know about your family’s income. Your family includes everyone currently living with you who is related to you by birth, marriage, or adoption.
Including yourself, how many family members currently live with you?
_______ members
___ Don’t know
___ Refused
Can you tell me your total family income in {LAST CALENDAR YEAR} before taxes?
SHOW CARD.
(Check one only.)
___ 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
___ Don’t know
___ Refused
FISHING INFORMATION
Have you heard about the health advice on eating fish caught from New York State waters?
___ Yes
___ No
___ Don’t know
___ Refused
END OF INTERVIEW.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Irvin-Barnwell, Elizabeth (ATSDR/DHS/HIBR) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |
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