Form 10.3 Survey

OMB Control Number: 0925-0593

Expiration Date: 07/31/2013

Environmental Tap Water TWQ Participant Collect SAQ, Phase 2e

Environmental Tap Water Pesticide (TWQ) Participant Collect SAQ

(EH, PB, HI) V1.0

Event:	Pregnancy Visit 1
Participant:	Pregnant Woman
Domain:	Environmental
Type of Document:	Self-Administered Questionnaire
Recruitment Groups:	EH, PB, HI

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Tap Water TWQ Collection

Follow the instructions in your booklet when collecting the TWQ sample.

1. How many bottles did you fill?

(P_TWQ_N_COLLECT)

₂ 2 (GO TO QUESTION 4)

₁ 1 (GO TO QUESTION 2)

₀ 0 (GO TO QUESTION 3

	2 (P_TWQ_1_COLLECTED) . Why did you only fill one bottle? 1 Supplies missing from kit 2 Didn’t have time 3 Couldn’t schedule pick-up -5 Other, specify _____________________ (GO TO QUESTION 4)
0	3 (P_TWQ_0_COLLECTED) . Why didn’t you collect any bottles? 1 Supplies missing from kit 2 Didn’t have time 3 Couldn’t schedule pick-up 4 Decided not to collect sample -5 Other, specify _____________________ (END FORM)

For Office Use Only

Participant ID: ____________________________

Event: Pregnancy Visit 1

4. TWQ sample IDs:

AFFIX LABEL FOR EACH BOTTLE YOU FILLED

Affix

TWQ Bottle #1/2

Label here

(SAMPLE_ID) ONLY NEEDS TO BE ENTERED IN THE VDR ONCE BECAUSE SAMPLE IDS ARE EQUAL.

Affix

TWQ Bottle #2/2

Label here

5

2 0

. What date did you collect the TWQ sample?

Date: //

^{m m d d y y y y}

6

(P_TWQ_DAY)

. What day of the week did you collect the TWQ sample?

₁ Monday ₄ Thursday ₆ Saturday

₂ Tuesday ₅ Friday ₇ Sunday

₃ Wednesday

7

(P_TWQ_LOCATION)

(P_TWQ_LOCATION_OTH)

. Where was the TWQ sample collected?

₁ Kitchen tap

₂ Bathroom sink/tub

₃ Outside spigot/pump

_-5 Other, specify__________________________

_-1 Prefer not to answer

_-2 Don’t know

8

(P_TWQ_FILTERED)

. Is the water filtered? For example do you have a drinking water filter such as a Brita filter on the faucet where you collected the sample?

₁ Yes _-1 Prefer not to answer

₂ No _-2 Don’t know

9

(P_TWQ_WATERSOURCE)

. Is the tap water from your own household well?

₁ Yes _-1 Prefer not to answer

₂ No _-2 Don’t know

1

(P_TWQ_INSECTICIDE)

0. Have any products been used to kill insects in the room where you collected the TWQ sample in the past month?

₁ Yes _-1 Prefer not to answer

₂ No _-2 Don’t know

1

(P_TWQ_PROBLEMS)

(P_TWQ_PROBLEMS_OTH)

1. Did you have any problems collecting the TWQ sample?

MARK ALL THAT APPLY

₁ No problems

₂ Lost ice packs

₃ Lost foam inserts

₄ Lost labels

_-5 Other, specify__________________________

_-1 Prefer not to answer

_-2 Don’t know

Thank you very much for collecting the TWQ sample and completing this questionnaire! All of your answers are very important.

Please help us by looking at each question again to make sure that you...

• Did not skip any questions, and

• Marked out the wrong answer and marked the right answer if you made any changes.

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address

ENV Tap Water TWQ Participant Collect SAQ (EHPBHI), April 2012, V1.0 1