Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

Attachment 6g. NY eligibility screening survey, Burmese

Instructions: If participant is not a seed, ask questions #1-3. If the participant is a seed, begin with question #4.

1. Were you born in Burma or in a refugee camp in Thailand or Malaysia?

 Yes  go to #2

 No END OF SURVEY. “…you are not eligible to participate…”

2. What is your relationship to the person who gave you the coupon?

 Friend or acquaintance  go to #3

 Relative, does not live with me  go to #3

 Co-worker, supervisor, etc.  go to #3

 Relative or household member, lives with me  END OF SURVEY.

 Stranger END OF SURVEY.

If END OF SURVEY: “I am sorry, but you are not eligible to participate in this project. Thank you for coming in.”

3. Have you or anyone you live with already participated in this project?

 Yes  END OF SURVEY. “…you are not eligible to participate…”

 No go to #4

 Don’t know  Describe project and determine if the individual has already participated. (Verify later from the database of participants.)

4. How old are you? ______ years

If 18 years or older  go to #5.

If less than 18 years old  “…you are not eligible to participate…”

5.  Male  Female

6. Have you lived in Buffalo for longer than one year?

 Yes  go to #7

 No END OF SURVEY.

 Don’t know  END OF SURVEY.

If END OF SURVEY: “…you are not eligible to participate…”

Public reporting burden of this collection of information is estimated to average 5 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).

7. In the past 12 months, which of the following bodies of water did you fish from?

SHOW MAP.

(Check all that apply.)

 Foot of Ferry

 Squaw Island

 Squaw Island Ponds

 Black Rock Canal

 Scajagwada Creek

 Know it was from nearby water(s) but can’t remember the name

If one or more bodies of water or “nearby water” are checked  go to #8

 None

 Don’t know

If none or don’t know  END OF SURVEY. “…you are not eligible to participate…”

8. In the past 12 months, how many times did you eat fish caught in the bodies of water listed in #6?

____ times

 If ≥12 times: “You are eligible to participate in this project.”

 If <12 times: “…you are not eligible to participate…”

 Don’t know  “…you are not eligible to participate…”

END OF SURVEY.

Draft Map of the Buffalo and Lockport areas