Mother's Enrollment

Prospective Birth Cohort Study Involving Environmental Uranium Exposure in the Navajo Nation

Attach#3a_Mother Enroll_3-16-12

Enrollment for Mothers

OMB: 0923-0046

Document [docx]
Download: docx | pdf
Shape1

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx




Shape2 Participant Number: Survey Version _1_


Navajo Birth Cohort Study

ENROLLMENT SURVEY FOR MOTHERS

Date of Interview:

Interviewer Name:

Location of Interview:


RECORD OF CONSENT

If participant is under the age of 18 years a PARENTAL CONSENT TO PARTICIPATE IN RESEARCH with a parent’s and participant signature must be on file before proceeding any further.


I am going to read and explain two documents, called Consent to Participate in Research and HIPAA Form.

[Read the Consent Form. Make sure the participant initials each page and obtain participant's signature on the form before proceeding. Hand the participant a copy of the Consent Form after he or she has signed the original. You, the Interviewer, will keep the original signed consent form. Make sure the HIPAA and release forms are signed also.]


Was the Consent to Participate in Research/HIPAA Form read / explained in:


Navajo English Combination of both


Did the person consent to participate? Yes No


If yes, proceed with administration of the survey. If no, thank them for their time.



INTRODUCTION

If participant consented at an earlier time, start here. This is to ensure that they still qualify to be a participant in the study.


Are you still pregnant? Yes No Dont Know


[If no, go to sympathy statement and thank them for their time.] Would you like to be interviewed in the Navajo or English language?

Navajo English Combination of both


Is there any change in your contact information since we last spoke to you?

Yes No Dont Know


CONTACT INFORMATION

Mailing Address



Telephone Number – Home

Cell

Message


E-mail address

Shape3

Public reporting burden of this collection of information is estimated to average 120 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 (0923-XXXX).



1

Shape4 Participant Number: Survey Version _1_

Navajo Birth Cohort Study

ENROLLMENT SURVEY FOR MOTHERS


The purpose of this study is to look into community concerns about whether exposure to uranium mining and milling waste affects the outcome of pregnancies and the development of Navajo children. The proposed research will provide a public health benefit through education on environmental prenatal risks and provide earlier assessment and referral for identified developmental delays. Finally, the results of this study will provide the first Navajo-Nation-wide documentation of birth outcomes and developmental delays. Information gathered and analyzed will be provided to the tribe and Navajo

Area Indian Health Service which may be used to improve future birth outcomes and services.


Before we begin the questionnaire, do you think your babys father would be willing to participate in the study with you and your baby?

Yes

No

Dont know

Refused


If the father of your baby is a minor (less than 18 years old), his parents must be contacted and consent to his being in the study. How old is your babys father?

Less than 18 years old

Greater than 18 years old

Dont know

Refused


If you have not talked with the father of your baby about participating in the study would you like to speak with him before we contact him?

Yes

No

Dont know

Refused


Are you willing to give us the name of the father of your baby, so that we may contact him and ask if he is willing to participate in the Navajo Birth Cohort Study?

Yes

No

Dont know

Refused


If you dont mind if we contact him, please provide his name and contact information below: Name


Phone number


Location of home











2

Shape5 Participant Number: Survey Version _1_

DEMOGRAPHICS



1. What is your date of birth?

/ / MM DD YYYY


2. Where were you born?

City or town State

Country



3. What language do you speak most often?

3a. At work? English Navajo Both Other


3b. At home with family? English Navajo Both Other


3c. With friends? English Navajo Both Other


4.Are you married or living with a partner? Yes No


4.a. If no, are you: Never married or lived with partner

Separated from husband or partner

Divorced

Widowed


5. What is the highest grade of school you have completed or the highest degree you have received?

No education

1st to 6th grade

7th to 9th grade

10th to 12th grade, no diploma

High school graduate/GED

Bachelors degree

Some college, no degree

Associate degree

Graduate or professional degree

Other specify

Dont know

Refused


6. Are you currently a student? Yes No


7. What is your current paid employment status?

Unemployed

Self-employed

Employed part-time

Employed full-time











3

Shape6 Participant Number: Survey Version _1_


8. What is your best estimate of your total personal income from all sources in the past year (before taxes)? If annual income not known, ask What is your best estimate of your monthly income? and choose from the choices below.

Less than or equal to $4,999 per year ($417 monthly)

$5,000 - $9,999 per year ($418 $833 monthly

$10,000 - $19,999 per year ($834 - $1666 monthly)

$20,000 - $39,999 per year ($1667 $3333 monthly)

$40,000 - $69,999 per year ($3334 $5833 monthly)

More than $70,000 per year ($5834 monthly)

Dont Know

Refused


9. Household income means income for everyone in your household, taken together. What is your best estimate of your total household income before taxes from all sources in the past year?

Less than or equal to $4,999 per year ($417 monthly)

$5,000 - $9,999 per year ($418 $833 monthly

$10,000 - $19,999 per year ($834 - $1666 monthly)

$20,000 - $39,999 per year ($1667 $3333 monthly)

$40,000 - $69,999 per year ($3334 $5833 monthly)

More than $70,000 per year ($5834 monthly)

Dont Know

Refused


Now, I am going to ask you a few questions about your babys father.


10. Would you be willing to answer these questions? Yes No Refused

(If refused, go to Reproductive History- Question 15)


11. Is your babys father Navajo? - Yes No


12. If not, what is the race or ethnicity of your babys father? (Check all that apply) African American or black Yes No

American Indian or Alaska Native Yes No

Asian Yes No Hispanic Yes No Native Hawaiian or Other Pacific Islander Yes No White Yes No

Other, specify

Yes No

Dont know Yes No

Refused Yes No


13. What is the highest grade of school you have completed or the highest degree you have received?

No education

1st to 6th grade

7th to 9th grade

10th to 12th grade, no diploma

High school graduate/GED Bachelors degree

Some college, no degree

Associate degree

Graduate or professional degree

Other specify

Dont know




4

Shape7 Participant Number: Survey Version _1_


REPRODUCTIVE HISTORY


14. How old were you when you had your first menstrual period? | | |

............................................................................. AGE IN YEARS


15. Before you became pregnant, what was the usual pattern of your menstrual cycles (when not pregnant or breastfeeding or using birth control pills)?


Always irregular

Usually irregular

Regular (within 5-7 days of expected)

Very regular (within 3-4 days of expected)

Extremely regular (no more than 1-2 days before or after expected)

Dont know

Refused


16. Have you ever used birth control pills? Yes No Refused



17. What is your usual form of birth control? Choose only one answer.

None

Rhythm method or counting of days in cycle

Condom or other barrier method (diaphragm or cervical cap)

IUD (intrauterine device)

Birth control pills

Birth control patch (Ortho-Evra) or ring (Nuvaring)

Birth control shots (Depo Provera) or injectable estrogen (Lunelle)

Other Specify

Refused or dont know


18. How old were you at your first pregnancy?


| | | Refused

AGE IN YEARS


19. Besides your current pregnancy, how many pregnancies have you had?


| | |......................................................... Refused

NUMBER


20. Have you ever had a miscarriage (spontaneous abortion)?

Yes

No

Dont know

Refused


21. Have you ever had a still-born child (baby was not alive at birth)?

Yes

No

Dont know

Refused






5

Shape8 Participant Number: Survey Version _1_


22. How many live-born children have you had? ........................


| | | Refused

NUMBER


23. Have any of your children been diagnosed with developmental delay, a birth defect or immune system problems?

Yes

No

Dont know

Refused


If yes please start with oldest child and work your way to the youngest

Gender Date of Birth Diagnoses Receiving Care Where

Shape9 Child #1. Boy Girl / /


Shape10 Child #2. Boy Girl / /


Shape11 Child #3. Boy Girl / /


Shape12 Child #4. Boy Girl / /


Shape13 Child #5. Boy Girl / /


Shape14 Child #6. Boy Girl / /


24. Have you ever delivered or received prenatal care in any the following health-care facilities?

Chinle Comprehensive Health Care Facility

Ft. Defiance Indian Hospital

Gallup Indian Medical Center

Kayenta Health-Center

Northern Navajo Medical Center (i.e., Shiprock Hospital)

Tuba City Regional Health-Care Corporation

Other


25. Have you ever breastfed your children for more than two weeks?

Yes→ If yes, specify below the number of months breastfed FOR EACH CHILD

No - This is my first baby.

No - I have not breastfed any of my other children.

Refused


Start with your oldest child and work your way to the youngest

Gender Date of Birth Number of Months Breastfed

Child #1. Boy Girl / /


Child #2. Boy Girl / /


Child #3. Boy Girl / /


Child #4. Boy Girl / /


Child #5. Boy Girl / /


Child #6. Boy Girl / /

6

Shape15 Participant Number: Survey Version _1_


26. Have you ever carried a pregnancy with multiple babies (twins, triplets, etc.)? Yes No


27. Have you or your partner sought treatment for fertility concerns? Yes No


28. Have you ever taken fertility medications? (such as hormone treatments) Yes No


CURRENT PREGNANCY INFORMATION


29. What is your due date? / / DD MM YYYY


30.Do you know if you are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

Dont know

Singleton

Twins

Triplets or Higher

Refused


31. Are you getting prenatal care? Yes No Refused



Shape16 31a. If yes, where are you getting prenatal care?



NAME OF PRENATAL CLINIC


31b. How many weeks pregnant were you when you had you first prenatal clinic visit?


| | | ....................................... Dont know

NUMBER OF WEEKS


32. Are you receiving prenatal care from a traditional practitioner? Yes No


33. What was your weight before you became pregnant? ........... | | | | Dont know

............................................................................. POUNDS Refused


34. In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

Yes

No

Dont know

Refused


35. Do you plan to breastfeed your new baby?

Yes

No

Dont know

Refused







7

Shape17 Participant Number: Survey Version _1_


36. Are you currently receiving WIC assistance?

Yes

No

Dont know

Refused

CURRENT MEDICATION AND SUBSTANCE USE


37. Since youve become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

Yes

No

Dont know

Refused


38. Are you currently taking doctor-prescribed medications and/or vitamins on a daily basis?

Yes What [prescribed] medications do you take?

38a.


38b.


38c.


38d.



No

38e.


39. Are you currently taking over-the-counter (non-prescription) medications and/or vitamins on a daily basis?

Yes What [over the counter medications] do you take?

39a.


39b.


39c.


39d.



No

39e.


40. Are you currently taking herbal supplements on a daily basis?

Yes What herbal supplements do you take?

40a.


40b.


40c.


40d.



No

40e.


8

Shape18 Participant Number: Survey Version _1_


41. Are you currently using any traditional or home remedies?

Yes What remedies do you take?

41a.


41b.


41c.


41d.



No

41e.


42. It often takes a few months to find out you are pregnant. During that period when you didnt know you were pregnant, is it possible you may have used any of the following?

Marijuana

Street or recreational drugs such as cocaine, ecstasy, methamphetamine

Alcohol (including beer)


43. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctors prescription for?

Yes 43a. How many times?

Once or twice

10 or more times

Dont know

Refused

No


44. Are you currently smoking marijuana?

Yes

No

Refused


45. Are you currently using other recreational or street drugs, including drugs that you smoke or inject?

Yes What drugs are they?

45a.


45b.


45c.


45d.



No

45e.











9

Shape19 Participant Number: Survey Version _1_


46. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctors prescription for?

Yes 46a. How many times?

Once or twice

10 or more times

Dont know

Refused

No


ALCOHOL USE


47. How often did you have a drink containing alcohol in the past year?

Never

Monthly or less

Two to four times a month

Two to three times a week

Four or more times a week


48. How many drinks containing alcohol did you have on atypical day when you were drinking in the past year?

0 drinks

1 or 2

3 or 4

5 or 6

7 to 9


49. How often did you have six or more drinks on one occasion in the past year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily




TOBACCO USE


50. Do you smoke tobacco only for ceremonial use?

Yes [skip to 59]

No


51. In your lifetime, have you smoked as many as 100 cigarettes?

Yes

No→ [skip to 59]


52. Was there ever a time that you smoked at least 1 cigarette a day for a month or longer?

Yes

No→ [skip to 59]


53. Do you now smoke cigarettes (not including those for ceremonial use only)?

Yes

No





10

Shape20 Participant Number: Survey Version _1_


54. For about how many years total would you say that you smoked at least 1 cigarette per day?


| | | ................................................. Dont Know

YEARS


55. During the time you smoked at least 1 cigarette a day, about how many cigarettes a day on average?


| | _|

cigarettes/day ......................................... Dont Know


56. When was your last cigarette?

Today

In the past week

More than a week ago

More than a month ago

Before pregnancy

Dont know

Refused


57. Did you ever quit smoking for 6 months or longer?

Yes If Yes: 57a. Did you quit because of your pregnancy?

Yes

No

No


58. If you stopped smoking cigarettes and then started smoking again, for how many years did you quit?


| | |

| | |

Dont Know

months quit

years quit



59. Does anyone else in your household smoke on a daily basis?

Yes

No

Dont know

Refused

If yes 59a. How often do household members or guests smoke cigarettes in your home?

Daily

Weekly

Monthly


STRESS


The following questions ask about your feelings and thoughts during the last month. In each case, please tell me how often you felt or thought a certain way.


60. During the last 30 days, about how often did you feel so depressed that nothing could cheer you up?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

11

Shape21 Participant Number: Survey Version _1_



61. During the last 30 days, about how often did you feel hopeless?

All of the time

Most of the time

Some of the time

A little of the time

None of the time


62. During the last 30 days, about how often did you feel restless or fidgety?

All of the time

Most of the time

Some of the time

A little of the time

None of the time


63. During the last 30 days, about how often did you feel that everything was an effort?

All of the time

Most of the time

Some of the time

A little of the time

None of the time


64. During the last 30 days, about how often did you feel worthless?

All of the time

Most of the time

Some of the time

A little of the time

None of the time


65. During the last 30 days, about how often did you feel nervous?

All of the time

Most of the time

Some of the time

A little of the time

None of the time


PHYSICAL ACTIVITY


66. During the past month, other than for your regular job, did you participate in any physical activities, such as running, gardening, aerobics, dancing, basketball, walking for exercise, herding sheep, chopping wood, or horseback riding?

Yes

No

Dont know

Refused


67. How often do you exercise? (Such as the activities above)

Once or more per week

Once per month

On occasion

Never





12

Shape22 Participant Number: Survey Version _1_



68. What is your primary mode of transportation?

Car

Bus

Hitchhiking

Horseback

Walking

Other Specify



HOUSING CHARACTERISTICS


69. What is the location of your home?

Shape23 [The participant may give his or her house number and street/road name, rural address, nearest highway or natural feature, or distance from Chapter House.]





70. Is the house you are living in…?

Owned or being bought by you or someone in your household

Rented by you or someone in your household, or

Some other arrangement

Dont know

Refused


71. Can you tell us, which of these categories do you think best describes when your home or building was built?

2001 TO present

1981 TO 2000

1961 TO 1980

1941 TO 1960

1940 or before

Dont know

Refused


72. How long have you lived in this home?

| | | Weeks

NUMBER .... Months

......... Years

......... Dont know

......... Refused


73. What type of home do you live in?

Hogan

Modular or site-built house

Mobile home

Multi-family dwelling or Apartment building

Seasonal camp or lodging

Hotel /motel or other temporary housing

Other Specify

Dont know

Refused




13

Shape24 Participant Number: Survey Version _1_



74. What is the construction of your home? (Check all that apply)

Mobile home

Wood frame

Stone

Adobe

Crawlspace or basement

Dirt floor


75. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, tarps, utility poles, railroad ties, or other materials from an abandoned uranium mine or mill?

Yes












No

75a.If yes which materials were used Wood

Sheet metal

Metal pipes

Rocks

Sand

Tarps

Utility poles

Railroad ties

Other:

Dont know

Refused


76. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, utility poles, railroad ties, or other materials from oil and gas operations?

Yes











No

76a.If yes which materials were used Wood

Sheet metal

Metal pipes

Rocks

Sand

Utility poles

Railroad ties

Other:

Dont know

Refused


77. Including yourself, how many people live in your home?


| | | NUMBER


78. Excluding bathrooms, how many total rooms are in your home?


| | | NUMBER


79. Which of these types of heat /fuel sources do you use to heat your home?

Electric

Gas-Natural

Gas-Propane or LP

14

Shape25 Participant Number: Survey Version _1_

Oil

Wood

Kerosene or diesel fuel

Coal

Solar energy

Wind power

No heating source

Other specify

Dont know

Refused


79a.If you burn wood or coal in your home, what is the approximate age of your stove.

1-5 yrs

5-10 yrs

10-15 yrs

>15 yrs


79b.If you burn wood or coal in your home, how often do you personally tend the fire?

Once per day

1-5 x per day or more

Once per week

1-3 times per week

Occasionally


80. How do you cool your home? SELECT ALL THAT APPLY.

Fan

Window or wall air conditioners

Central air conditioning

Evaporative cooler (swamp cooler)

No cooling or air conditioning used

Other specify

Dont know

Refused


81. In the past 12 months, have you seen any water damage inside your home?

Yes

No

Dont know

Refused


82. In the past 12 months, have you seen any mold or mildew on walls or other surfaces inside your home?

Yes

No

Dont know

Refused


83. Since you became pregnant, have any additions been built onto your home to make it bigger, or have any renovations or other construction been done in your home? Include all projects such as painting, wallpapering, carpeting or re-finishing floors.

Yes

No

Dont know

Refused


15

Shape26 Participant Number: Survey Version _1_



84. Do you have any pets that spend any time inside your home?

Yes

No

Dont know

Refused


85. What kind of pets are these? SELECT ALL THAT APPLY.

Dog

Cat

85a. Do you change the cat box? Yes No

Lambs or baby goats

Small mammal (rabbit, gerbil, hamster, guinea pig, ferret)

Bird (including chicks)

Fish or reptile (turtle, snake lizard)

Other specify

Dont know

Refused


86. Do you tend livestock on a regular basis in a corral or around your home?

Yes

No


87. Please tell us all the places you have lived throughout your life, even as a child, and how long you lived at each place.


Chapter

Location Description


# of years


| | |




| | |




| | |




| | |




| | |




| | |




| | |




| | |




WATER USAGE


88. Is your home connected to a community water system piped in to your home?

Yes No Dont Know


88a.If yes, what is the name of the water system?


88b.If yes, is this your main source of drinking water? Yes No Dont Know


16

Shape27 Participant Number: Survey Version _1_


89. Do you haul water? Yes No Refused


89a.If you haul water, what type of container do you use to haul water?

Plastic

Metal

Glass

Wood

Other Specify

Dont know


89b.If you haul water, where do you haul water from? [Check all that apply]

Lake/pond

Stream/river

Spring

Rain Water

Irrigation Water

Cistern or tank at windmill

Windmill

Private well

Grocery or convenience store/ trading post

Navajo Tribal Utility Authority (NTUA) or other public water supply

Other Specify

Dont know


89c. If yes, in what types of containers do you store this hauled water?

Plastic

Metal

Glass

Wood

Concrete

Other Specify

Dont know


89d.If you haul water, do you filter the water you haul?

Yes

If yes, what filters do you use?

Charcoal filter

Ceramic filter

Distillation

Boil

Disinfect

No, dont do anything to the water

Dont know


89e. How many places do you currently haul water from? | | |

............................................................................. NUMBER











17

Shape28 Participant Number: Survey Version _1_


90. Using the map, can you identify the location of any water sources from which you or someone in your household has hauled water for drinking or other household use?


Please note all uses of this water for each source identified.


Name/Number of Uses of the water (drinking, cooking, livestock Number of years

Water Source watering, irrigation, bathing, other household uses)


| | |


| | |


| | |


| | |


| | |


| | |


| | |


| | |


91. What water source in your home do you use most of the time for drinking?

Hauled water

Tap or piped in water

Filtered tap/piped in water

Bottled water

Other specify

Dont know

Refused


92. What water source in your home is used most of the time for cooking?

Shape37 Hauled water

Tap or piped in water

Filtered tap/piped in water

Bottled water

Other specify

Dont know

Refused


FOOD BEHAVIORS


93. Do you eat the meat of the livestock you raise? Yes No Dont know


Shape38 93a.Where do the livestock graze? (Using map, locate grazing area)



Shape39 Shape40 Shape41 93b.Where do they get water? (Using map, locate wells, springs, ponds, etc.)






18

Shape42 Participant Number: Survey Version _1_


94. Please tell us what animals you eat and the specific parts you eat, including the organs.


Sheep/Goat Cattle Horse Pig Chicken Turkey


Muscle Liver Kidney Brain Intestine Testicles


Tongue Heart Other


94a. In the last month, have you eaten any food that was blackened, charred, or roasted through cooking? Yes No

94b. If yes, how many servings?

1-2 3-5 6-10 11-19 20+


95. Do you eat the vegetables or fruit you grow? Yes No Dont know


96. Do you use the water you haul for the vegetables you grow? Yes No Dont know


97. Please tell us what vegetables or fruits that you grow and eat:


Apples

Apricots Beans

Bell Peppers

Carrots

Chile

Corn

Cucumbers Melons

Onions

Peaches

Potatoes

Squash

Strawberries

Tomatoes



Other


98. Do you gather and eat vegetation from the wild?

Yes










No

If Yes Wild Onions

Wild Carrots

Wild Berries

Cedar tree berries

Pinõn nuts

Yucca Fruit

Others:

Dont know

Refused


99. Are you receiving WIC?


Yes No Dont know


99a. If yes skip to Occupational and Environmental History.


99b. If no go to Food Frequency Questions or make follow-up appointment


Date

Time

Location



OCCUPATIONAL

OCCUPATIONAL AND ENVIRONMENTAL HISTORY


100. Have you ever been employed outside of the home?

Yes

No

Refused

19

Shape43 Shape44 Participant Number: Survey Version _1_


If no, skip this section

If yes, please answer the following:


101. At any of your jobs, have you ever handled or come into contact with pesticides (bug or weed spray), other chemicals, or toxic or potentially dangerous substances?

Yes

No

Dont know

Refused


101a.If yes, complete the following

Shape45 Shape46 Substance Brand/Name Used Indoor Used outdoors How Long


Shape47 Pesticide


Shape48 Chemicals


Shape49 Shape50 Other



102. Have you worked in any of the following industries outside your home? If yes, how long (years)?

Shape51 Number of Years

Shape52 Gold and/or silver mining ............................................ | | |


Coal mining ................................................................ | | |


Uranium mining / milling ............................................. | | |


Uranium reclamation................................................... | | |


Uranium ore hauling ................................................... | | |


Other mining (e.g., copper, iron, lead, vanadium) ...... | | |


Petroleum or natural gas production .......................... | | |


Electronics manufacturing .......................................... | | |


Plastics manufacturing ............................................... | | |


Gold/Silversmithing..................................................... | | |


Roadwork/paving ....................................................... | | |


Military (depleted uranium, high explosives) ............... | | |


Electric/transmission line/Utility crew | | |


Pottery ....................................................................... | | |


Lapidary...................................................................... | | |


Weaving ..................................................................... | | |


20

Shape53 Participant Number: Survey Version _1_

Livestock (herding, transporting, working in a feed-yard) | | |


Other Specify | | |


103. Have you or anyone in your household done any of the following activities in your home?

If yes, how long (years)?

Number of Years

Electronics | | |


Plastics | | |


Gold/Silversmithing | | |


Pottery | | |


Lapidary | | |


Weaving | | |


Other Specify | | |


104. If you do lapidary work in your home, do you use

Block or synthetic stones

Stabilized stones

Only natural stone

Dont know


105. If you make jewelry in your home, do you use solder?

Yes

No

Dont know

Refused


ENVIRONMENTAL


106. Have you ever lived near an agricultural area or farm?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 106a. Number of years | | | 106b. Where?

No

Dont know


107. Have you ever lived near a toxic waste site or waste dump or landfill?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 107a. Number of years | | | 107b. Where?

No

Dont know










21

Shape54 Participant Number: Survey Version _1_


Shape55 108. Have you ever lived near a chemical factory or plant?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 108a. Number of years | | | 108b. Where?


Shape56 108c. Chemicals used or manufactured there


No

Dont know


109. Have you ever lived near a uranium mine?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 109a. Number of years | | | 109b. Where?

No

Dont know


110. Have you ever lived near a uranium mill?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 110a. Number of years | | | 110b. Where?

No

Dont know


111. Did either of your parents or grandparents work in a uranium mine or mill?

Yes

No

Dont know

111a. If yes

Shape57 Shape58 Shape59 Shape60 Shape61 Shape62 Name of Mine or Mill Number of Years worked there












112. Did anyone in your household work in a uranium mine or mill at any time during your lifetime?

Shape63 Yes

No

Shape64 Shape65 Dont know

112a. If yes

Shape66 Shape67 Shape68 Shape69 Shape70 Number or years Your age at the time












Shape71 22

Shape72 Participant Number: Survey Version _1_


113. Can you think of any other ways you might have come in contact with uranium, such as:

113a. Playing on a uranium tailings pile or waste dump?

Yes No

113b. Playing outdoors near or next to a uranium mine, mill or waste dump?

Yes No

113c. Drinking, wading into or coming into contact with uranium mine water or waste spills?

Yes No

113d. Herding livestock on or next to a uranium mine, mill or waste dump?

Yes No

113e.Sheltering livestock in an abandoned mine?

Yes No

113f. Living in a mining camp?

Yes No

113g.Washing or handling clothes of a friend or family member who was a uranium worker?

Yes No

113h. Live in the same home with a uranium miner or miller?

Yes No


114. Have you ever lived near an oil and gas facility, such as a oil or natural gas well, petroleum refinery, natural gas plant or natural gas compressor station?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 114a. Number of years | | | 114b. Where?

No

Dont know


115. Have you ever lived near a coal-fired electric generating station, coal waste dump or coal mine (surface or underground)?

By near,” I mean downwind of, along a road, in a floodplain, or within two miles


Yes 115a. Number of years | | | 115b. Where?

No

Dont know





THANK YOU FOR YOUR PARTICIPATION




23

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
Authorhlb8
File Modified0000-00-00
File Created2021-01-31

© 2024 OMB.report | Privacy Policy