10.4 Survey

OMB Control Number: 0925-0593

Expiration Date: 07/31/2013

Environmental Vacuum Bag Dust (VBD) Participant Collect SAQ, Phase 2e

Environmental Vacuum Bag Dust (VBD) 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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Vacuum Bag Dust (VBD) Collection

Follow the instructions in your booklet when collecting the vacuum bag dust sample.

(SAMPLE_ID)

1. Vacuum Bag Dust (VBD) sample ID:

Affix

vacuum bag dust sample ID

label here

2

(P_VBD_DATE)

. What date did you collect the VBD sample?

Date: //2  0

^{m m d d y y y y}

3

(P_VBD_DAY)

. What day of the week did you collect the vacuum bag sample?

₁ Monday ₄ Thursday ₆ Saturday

₂ Tuesday ₅ Friday ₇ Sunday

₃ Wednesday

For Office Use Only

Participant ID: ____________________________

Event: Pregnancy Visit 1

4. Approximately, how long has it been since you changed your vacuum bag or emptied the dust from your vacuum cleaner? Enter the number and select the time period from the choices below.

P_VACUUM_BAG_CHANGED P_VACUUM_BAG_CHANGED_FREQ

|___|___|

₁ Days ₃ Months _-1 Refused

₂ Weeks ₄ Years _-2 Don’t know

5

P_ VAC_USED_OUTSIDE

. Since the vacuum bag was changed or since you emptied the dust from your vacuum, has your vacuum been used in a place other than inside your home such as …?

MARK ALL THAT APPLY

₁ Your car

₂ Your garage

₃ Your porch

₄ Someone else’s home

₅ A hallway outside your apartment

_-5 Other, specify_______________________

_-7 Not applicable, vacuum only used in home

6

P_ VACUUM_TYPE

. What type of vacuum are you collecting the sample from?

₁ Standard vacuum (with a disposable bag)

₂ Bagless vacuum

₃ Handheld vacuum (with a disposable bag)

₄ Handheld vacuum (without a bag or with a reusable cloth bag)

₅ Central house collection system

₆ Robotic vacuum

₇ Hard surface vacuum (with a disposable bag)

₈ Hard surface (without a bag or with a Reusable cloth bag)

₉ Shop vac

_-5 Other, specify______________________

7

P_ VACUUM_MAKE_MODEL

. What is the make and model of the vacuum that you collected the sample from?

For example:

Make: Hoover

Model#: Windtunnel Rewind H09A

Make: _______________________

Model#: ______________________

8

P_ VACUUM_BAG

. If you have a standard vacuum with a bag, did you include the vacuum bag with the vacuum dust sample?

₁ Yes, bag was included intact

₂ No, dust was removed from bag

₃ Yes, bag was included, but it was ripped

_-5 Other, specify_______________________

9

P_ VACUUM_MOST_USED

. Is this the most used vacuum in your home?

₁ Yes _-1 Prefer not to answer

₂ No _-2 Don’t know

1

P_ VACUUM_PROBLEMS

0. Did you have any problems collecting the VBD sample?

MARK ALL THAT APPLY

₁ No problems

₂ Trouble removing bag/cup

₃ Lots of dust fell on towel

₄ Trouble putting vacuum back together

_-5 Other, specify_______________

Thank you very much for collecting the vacuum bag dust 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 15 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