NY Burmese Questionnaire

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx xxxxxx/xx/xx/20xx

Attachment 6i. NY Interview questionnaire, Burmese

New York State Biomonitoring of the Great Lakes Populations

Interview Questionnaire for Refugees from Burma

BACKGROUND INFORMATION

1. What is your full name (as appears on your NYS ID card)?

Full name: ____________________________________________________________

1. Sex (If unsure, ask his/her sex.)

___ Male

___ Female

3. What is your birthdate? (Use NYS ID card.)

____ / _____ / _______

mm dd yyyy

4. Age: _____ years

5. 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 the participant.)

___ Yes  _____________________ Home Work Cell Other: _________

_____________________ Home Work Cell Other: _________

___ No

___ Don’t know

___ Refused

6. Do you have an email address?

___ Yes  What is it? ________________________________

___ No

___ Don’t know

___ Refused

1. Public reporting burden of this collection of information is estimated to average 60 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).

Script: We would like to give you the results of the blood and urine testing. When we receive the results, someone will help explain them to you.

7. Do you want to know the results of your blood and urine tests?

___ Yes  go to #8

___ No  go to #8

___ Don’t know  Re-explain why results are important and useful.

___ Refused

8. Do you want your blood and urine results sent to your doctor or clinic?

___ Yes  go to #9

___ No  go to #10

___ Don’t have a doctor/clinic  Go to script* and ask #8 again, or go to #10.

___ Don’t know  Go to script* and ask #8 again, or go to #10.

___ Refused

9. What is his/her name, telephone number, and address?

Name of doctor or clinic: ______________________________

Telephone number: _________________

Address: ___________________________________________

* Use this script if participant does not provide physician’s name or does not have a physician/clinic. If you do not want the results sent to your doctor or you don’t have one, the results will be sent to a doctor at the New York State Department of Health. When we receive the results, someone will help explain them to you, and the doctor at the Department of Health can answer any questions you have.

DEMOGRAPHICS

10. In what country were you born?

___ United States

___ Burma/Myanmar

___ Thailand

___ Malaysia

___ Other country  Specify: _________________________

___ Don’t know

___ Refused

11. What tribe do you belong to?

___ Karen ___ Mon

___ Kachin ___ Rakhine

___ Chin ___ Other  Specify: _________________________

___ Karenni ___ Don’t Know

___ Burman ___Refused

REPRODUCTIVE HISTORY

FEMALES only. If MALE  go to #18

12. Are you pregnant?

___ Yes  go to #13

___ No  go to #14

___ Don’t know  go to #14

___ Refused  go to #14

13. When is your due date?

____ / _____ / _______

mm dd yyyy

___ Don’t know

___ Refused

14. How many babies have you given birth to?

Number: ______ (If none or no live births, enter “0”  go to #17)

___ Don’t know  go to #17

___ Refused  go to #17

15. Have you ever breastfed any of your babies?

___ Yes

___ No  go to #18

___ Don’t know  go to #18

___ Refused  go to #18

16. Are you breastfeeding any children now?

___ Yes

___ No

___ Don’t know

___ Refused

17. Tell me about the children you breastfed from your first child to the most recent child.

Birth order	Birth year (yyyy)	Number of months breastfed	Birth order	Birth year (yyyy)	Number of months breastfed
1st			5th
2nd			6th
3rd			7th
4th			8th

HOUSEHOLD INFORMATION

18. What is your street address?

Street Number: ________

Street Name:_________________________________

Apartment Number: ______________

Unit: ________ (or “upper” or “lower” floor)

City: _____________________ State: _______ ZIP Code: ________

19. Including yourself, how many family members currently live with you (including children) at this address?

If the participant lives alone  go to #22

Total number: _____

___ Don’t know

___ Refused

20. How many of the people who live with you are female and how many are male?

Female: _____

Male: _____

___ Don’t know

___ Refused

21. How many of the people who live with you are under the age of 15?

Number under 15 years: _____

___ Don’t know

___ Refused

WORK HISTORY AND EDUCATION

22. Do you work?

___ Yes  go to #23

___ No  go to #27

___ Don’t know  go to #27

___ Refused  go to #27

23. Do you work full time or part time?

___ Full time

___ Part time

___ Don’t know

___ Refused

24. What is your current job? Title: _______________________________

Where do you work? Industry name: ___________________________________________

How many hours a week do you work at this job? _____ hours per week

How much are you paid per hour? $ _____ per hour

25. Do you have a second job?.

___ Yes  go to #26

___ No  go to #27

___ Don’t know  go to #27

___ Refused  go to #27

26. What is your second job? Title: _______________________________

Where do you work? Industry name: ___________________________________________

How many hours a week do you work at this job? _____ hours per week

How much are you paid per hour? $ _____ per hour

27. Have you worked at any (other) job in the past year?

___ Yes  go to #28

___ No  go to #30

___ Don’t know  go to #30

___ Refused  go to #30

28. Did you work full time or part time?

___ Full time

___ Part time

___ Don’t know

___ Refused

29. What was this other job? Title: _______________________________

Where do you work? Industry name: ___________________________________________

How many hours a week do you work at this job? _____ hours per week

30. Do you receive food stamps?

___ Yes

___ No

___ Don’t know

___ Refused

31. Do you receive WIC services?

___ Yes

___ No

___ Don’t know

___ Refused

32. How many years of school have you completed?

Number of years: _____  go to #33

___ None go to #34

___ Don’t know go to #34

___ Refused go to #34

33. Have you ever attended school in the United States?

___ Yes

___ No

___ Don’t know

___ Refused

34. Do you read?

___ Yes  Which language? (specify) _______________________________

___ No

___ Don’t know

___ Refused

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.

35. On most days, do you take or use any of the following?

(Check all that apply.)

___ Herbal medicine or supplements  Specify: _________________________________

___ Fish oil

___ Store-bought Betel nut

___ Natural or hand-made Betel nut

___ None

___ Don’t know

___ Refused

FEMALES only. If MALE  go to #38

36. Do you use a yellow powder/cream called Thanakar?

___ Yes  go to #37

___ No  go to #38

___ Don’t know  go to #38

___ Refused  go to #38

37. How often do you use Thanakar?

_____ times per (circle one) week month year

___ Don’t know

___ Refused

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

___ Yes (Ever smoker)  go to #38

___ No (Never smoker)  go to #43

___ Don’t know  go to #43

___ Refused  go to #43

39. (Ever smoker) Do you smoke cigarettes now?

___ Yes (Current smoker)  go to #41

___ No (Former smoker)  go to #40

___ Don’t know  go to #43

___ Refused  go to #43

40. (Former smoker) How long has it been since you last smoked cigarettes regularly?

_____ months or _____ years  go to #43

41. (Current smoker) How often do you smoke cigarettes?

___ Daily (Daily smoker)  go to #42

___ Weekly  go to #43

___ Monthly  go to #43

___ Don’t know  go to 43

___ Refused  go to #43

42. (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

43. Do you use chewing tobacco or snuff?

___ Yes  go to #44

___ No  go to #45

___ Don’t know  go to #45

___ Refused  go to #45

44. How often do you use chewing tobacco or snuff?

___ Daily

___ Weekly

___ Monthly

___ Don’t know

___ Refused

RESIDENTIAL HISTORY

Script: Please answer the following questions about how long you have lived in Buffalo and in places in the past.

45. How long have you lived in the United States?

_____ years and _____ months

___ Don’t know

___ Refused

46. How long have you lived in Buffalo, New York?

_____ years and _____ months

___ Don’t know

___ Refused

47. Have you lived in other cities in the United States other than Buffalo?

___ Yes  go to #48

___ No  go to #49

___ Don’t know  go to #49

___ Refused  go to #49

48. What other cities in the United States have you lived in?

1. City #1 (specify): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

2. City #2 (specify): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

49. Did you live in any refugee camps?

___ Yes  go to #50

___ No go to #51

___ Don’t know go to #51

___ Refused go to #51

50. Where were the refugee camps?

1. Camp #1 (location): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

2. Camp #2 (location): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

51. Did you live in any other countries?

___ Yes  go to #52

___ No go to #53

___ Don’t know go to #53

___ Refused go to #53

52. What other countries did you live in?

1. Country #1 (location): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

2. Country #2 (location): ________________________ 

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there? ___ times per (circle one) week month year

___ Don’t know

___ Refused

CONSUMED FISH

53. Have you eaten fish or shellfish in the past week?

___ Yes  go to #45

___ No  go to #46

___ Don’t know  go to #46

___ Refused  go to #46

54. 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

Script: The next group of questions is about the following bodies of water. (READ THE LIST.)

• Foot of Ferry / Broderick Park

• Squaw Island

• Squaw Island Ponds

• Black Rock Canal

• Scajaquada Creek

• Buffalo River

55. Have you eaten fish from any of these bodies of water? Which ones?

(Check all that apply.)

___ Foot of Ferry / Broderick Park

___ Squaw Island

___ Squaw Island Ponds

___ Black Rock Canal

___ Scajaquada Creek

___ Buffalo River

___ Don’t know

___ Refused

56. How often do you eat fish caught from these waters in each season?

(If never, enter 0 times per year.)

1. In summer? (months: June, July, August; description: when it’s hot outside)

_____ times per (circle one) day week month

___ Don’t know

___ Refused

2. In fall? (months: September, October; description: when it’s cold outside but not snowing)

_____ times per (circle one) day week month

___ Don’t know

___ Refused

3. In winter? (months: November, December, January, February, March; description: when there is snow on the ground)

_____ times per (circle one) day week month

___ Don’t know

___ Refused

4. In spring? (months: April, May; description: when it’s rainy, cool, but there’s no snow)

_____ times per (circle one) day week month

___ Don’t know

___ Refused

57. How do you get your fish from these waters during fishing season?

(Check all that apply)

___ Catch it

___ Received as a gift from friends/family

___ Collect from people fishing

___ Buy it down by the river/lake

___ Collect it from the water or ground (without fishing for it)

___ Don’t Know

___ Refused

58. Do you freeze these locally caught fish to eat later?

___ Yes

___ No

___ Don’t know

___ Refused

59. In the past year, about how many times did you swim, dive, or wade (including wading for fishing or hunting) in or near any of these bodies of water? (If needed, repeat the list of water bodies.)

(If never, enter 0 times per year.)

_____ times per (circle one) day week month

___ Don’t know

___ Refused

60. How many people in your family/household do you share fish with and eat fish caught from these bodies of water?

Total number of people who eat fish: _____  If participant lives alone, go to #62.

___ Don’t know  go to #62.

___ Refused go to #62.

61. How many of the people who eat the fish are children under 15 years old?

Number of children <15 years: _____

___ Don’t know

___ Refused

62. Which of the following fish caught from nearby waters have you eaten in the past 12 months? SHOW CARD.

___ American eel ___ Atlantic salmon ___ Black Crappie ___ Bluegill ___ Brook Trout ___ Brown Bullhead ___ Brown Trout ___ Channel Catfish ___ Chinook salmon ___ Coho salmon ___ Goldfish

___ Lake sturgeon ___ Lake trout ___ Largemouth (black) bass ___ Minnow ___ Muskellunge ___ Common Carp ___ Freshwater drum/Sheepshead ___ Northern pike ___ Pumpkinseed/Sunfish ___ Rainbow smelt ___ Rainbow trout/Steelhead

___ Rock bass ___ Smallmouth (black) bass ___ Walleye ___ White bass ___ White perch ___ White sucker/common sucker ___ Yellow perch ___ Round goby

Script: I’m going to ask you questions about how much of each fish you just told me you’ve eaten in the past 12 months and how you clean it, cook it, and what parts you eat.

63. In each season in the past 12 months, how many times did you eat [fish species]?

(If never, enter 0 times per year.)

1. Summer: ___ times per (circle one) week month year

___ Don’t know

___ Refused

2. Fall: ___ times per (circle one) week month year

___ Don’t know

___ Refused

3. Winter: ___ times per (circle one) week month year

___ Don’t know

___ Refused

4. Spring: ___ times per (circle one) week month year

___ Don’t know

___ Refused

64. How is the [fish species] usually cleaned before it’s cooked?

(Check all that apply.)

___ Don’t clean (no reason)

___ Too small to clean

___ Cut off head

___ Remove guts

___ Remove skin

___ Fillet (cut the large piece off the side)

___ Cut off belly fat

___ Don’t know

___ Refused

65. What parts of [fish species] do you usually eat?

(Check all that apply.)

___ Whole with head

___ Whole without head

___ Fillet (cut the large piece off the side)

___ Guts/innards

___ Skin

___ Head

___ Other  Specify: ___

___ Don’t know

___ Refused

66. How is the [fish species] usually cooked?

(Check all that apply.)

___ Fish pase

___Pan fried

___ Deep fried

___ Boiled/poached

___ Stew/chowder

___ Grilled

___ Baked/broiled

___ Eaten raw

___ Smoked

___ Dried

___ Pickled

___ Don’t know

___ Refused

STORE BOUGHT FOODS

Script: The following questions are about grocery store or market foods that you may have eaten in the past 12 months. We want to know about the foods you eat that have a lot animal fat diet.

In the past 12 months, how often did you eat meals with …..? SHOW CARD.

67. Whole eggs?

(If never, enter 0 times per year.)

____ times per (circle one) week month year

___ Don’t know

___ Refused

68. Whole milk products (including 2% milk)?

(If never, enter 0 times per year.)

____ times per (circle one) week month year

___ Don’t know

___ Refused

69. Poultry meat?

(If never, enter 0 times per year.)

____ times per (circle one) week month year

___ Don’t know

___ Refused

70. Red meat?

(If never, enter 0 times per year.)

____ times per (circle one) week month year

___ Don’t know

___ Refused

WILD BIRDS AND ANIMALS

71. In the past year, have you eaten any of these wild birds or animals?

SHOW CARD.

___ Waterfowl (ducks or geese)

___ Rats

___ Squirrel

___ Chipmunk

___ Ground hog

___ Skunk

___ Crows or other scavenger birds

___ Other (specify): ______________________________

___ None

___ Don’t know

___ Refused

STORE BOUGHT FISH

Script: The following questions are about fish you have eaten that were bought at a store, restaurant, fish vendor, open air market, Asian market or supermarket?

72. Which of these fish that was bought at a store, market, restaurant, or vendor have you eaten at least five times in your life?

(Check the species eaten at least 5 times.)

___ Grouper

___ Shark

___ Swordfish

___ Salmon (including canned)

___ Tuna (not canned)

___ Tuna (canned)

___ Shrimp

___ Snails

___ Mussels

If ate at least one type of fish  go to #73

___ None  go to #75

___ Don’t know  go to #75

___ Refused  go to #75

73. How many years did you eat [fish/shellfish]?

____ years

___ Don’t know

___ Refused

74. In the past year, how many times did you eat [fish/shellfish]?

____ times per (circle one) week month year

___ Don’t know

___ Refused

FISH PASTE

75. Do you eat fish paste [“nya u” (Karen) or “ngape” (Burmese)]?

___ Yes  How often do you eat fish paste [“nya u”] [“ngape”]?

___ times per (circle one) week month year

___ No  go to #80

___ Don’t know  go to #80

___ Refused  go to #80

76. Do you buy or make your fish paste [“nya u”] [“ngape”]?

___ I make my own

___ I buy my fish paste  go to #80

___ Don’t know  go to #80

___ Refused  go to #80

77. Do you make the fish paste [“nya u”] [“ngape”] from fish that you or someone you know caught in nearby waters?

___ Yes

___ No  go to #80

___ Don’t know  go to #80

___ Refused  go to #80

78. What kinds of fish do you or someone else use to make the fish paste [“nya u”] [“ngape”]? SHOW CARD.

(Check all that apply.)

___ American eel ___ Atlantic salmon ___ Black Crappie ___ Bluegill ___ Brook Trout ___ Brown Bullhead ___ Brown Trout ___ Channel Catfish ___ Chinook salmon ___ Coho salmon ___ Goldfish

___ Lake sturgeon ___ Lake trout ___ Largemouth (black) bass ___ Minnow ___ Muskellunge ___ Common Carp ___ Freshwater drum/Sheepshead ___ Northern pike ___ Pumpkinseed/Sunfish ___ Rainbow smelt ___ Rainbow trout/Steelhead

___ Rock bass ___ Smallmouth (black) bass ___ Walleye ___ White bass ___ White perch ___ White sucker/common sucker ___ Yellow perch ___ Round goby ___ Don’t know ___ Refused

79. What parts of the fish do you or someone else use to make the fish paste [“nya u”] [“ngape”]?

(Check all that apply.)

___ Whole fish

___ Flesh and skin only

___ Flesh only

___ Whole fish with head and tail removed

___ Other: (specify) ___________________________

___ Don’t know

___ Refused

FISHING INFORMATION

80. Have you heard about health advice on eating fish from nearby waters?

___ Yes  From who or where did you hear it? (specify) ____________________________

___ No

___ Don’t know

___ Refused

END OF INTERVIEW.