Att3 Chem Exp Question Bank 20130430

Attachment 3

Chemical Exposure Question Bank

Items from the question bank can be used to develop a survey for each submission.

Items marked with “*” are mandatory

[see http://minorityhealth.hhs.gov/templates/content.aspx?ID=9231&lvl=1&lvlID=10].

31 October 2011 - The Affordable Care Act requires new standards for the collection and reporting of health care information based on race, ethnicity, sex, and primary language. Making data standards consistent will help identify the significant health differences that often exist between and within ethnic groups. The new data collection requirements also will improve researchers' ability to consistently monitor more dimensions of health disparities among people with disabilities.

The use of all other items is not mandatory

All forms will display OMB Control Number, Expiration Date, and Public Reporting Burden

Example Script for Environmental and/or Biologic Sampling Events

Sample Introduction for Environmental Investigation:

Hello, my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention. As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions about your contact with chemicals. We are asking these questions to better understand all the data we collect.

The questions should take less than thirty minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR ENVIRONMENTAL-air, soil, water, foods testing] Once we are done with this investigation, you will be given a copy and details of -your location or the exposure location test results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.

Sample Introduction for Biologic Investigation:

Hello, my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention. As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions on your contact with chemicals. We are asking these questions to better understand all the data we collect.

The questions should take less than thirty minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR BIOLOGIC-blood, urine, hair, nails, other testing for all people who live in your home]. Once we are done with this investigation, you will be given a copy and details of -your and your minor children's (if you have them) test results]. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.

Questionnaire Categories

General Information Questions Example Script: Now I want to ask you questions about how I can contact you. I may also be asking how long you have lived at or visited certain places. This is needed to find out how long you may have had contact with chemicals and how long it may have lasted. We may also ask your age, race, weight and height, and about your jobs. This is useful to put your test results side by side with others like you to see what is typical. NOTE: It is recommended that you ask the general questions last.
(Name of Survey Taker HERE :)
(Investigation ID)	(For ATSDR, use Cost Recovery Number plus auto generated 2 digit hyphenated add on)
(Participant ID Number)	(May need a drop down if participant has been in a previous investigation)
(Relationship/Household ID)	(Use some way to connect participants to a location, family name, etc. Choose by keying in one of the following or some other where a drop down list appears to connect people): First Name/Last Name Street and #, City, St Exposure Location (Street. City, St or intersection) Building Room
(Laboratory ID)	(Given by lab. May be multiple if sample is split or divided into aliquots)
NOTE TO SURVEYOR: The following abbreviations and acronyms are used throughout. DK-Don’t know NA-Not applicable Mm/dd/year-2 digit month, 2 digit day, 4 digit year Ft-feet In-inches
(First name of person answering questions for minor child)
(Last name of person answering questions for minor child)
General Information
First name: (if minor child, put child’s name here)
Last name:
Middle Initial:
Street Address:
If this is an apartment, or the address has another defining number or letter, please provide that now:
City:
County:
State:
Zip Code:
Do you (or household head) rent or own this property?	Own	Rent	NA
If your mailing address is different from your street address, what is your mailing address?
City:
State:
Zip Code:
How long have you lived at this address?	Less than 6months	6mos to less than 2yrs	2 to5 yrs
	6 to10 yrs	More than10 yrs
How long have you lived at this address? (Note: use this question if you need a more exact date)	mm/year

How long have you lived in {Fill in Town, Neighborhood, or City of Interest}?	Less than 6 months			6mos to less than 2 yrs					2 to 5 yrs
	6 to10 yrs			More than 10 yrs
Previous Address Surveyor, ask for previous address if they have lived at current address less than a period you determine as a cut off. {6mos, 1 yr}.
What was your previous street address:
City:
State:
Zip Code:
Years at that address?
Please provide a phone number where we can reach you.	Home:		Work:				Cell:			Other:
Is there an email address where we can reach you? If yes, what is it?	No						Yes:
* How well do you speak English? (5 years old and older)	Very Well		Well				Not Well			Not at all
* Do you speak a language other than English at home? (5 years old and older)	Yes						No
* For persons speaking a language other than English (answering yes to the question above), what is the language? (5 years old and older)	Spanish			Other Language (Identify)
What is the occupation of the adults in the household? (Note to surveyor: You may want to ask this question here or with the list of jobs in the confounder section but probably not in both sections)	Animal Control Worker, Animal Scientist, Veterinarian Airport or Aircraft Worker Arts & Media Assemblers & Fabricator Car Repair, Mechanic Chemical Industry Worker (mixer, processor, researcher) Child Care Worker Cleaning homes or offices Construction Crop & Livestock Production Dentist, Dental Hygienist Detective and Criminal Investigator Disabled & stay at home Dry Cleaning Worker Fire Fighter Electrician, Electrical worker Engineering, Sciences & Education Equipment Operator Etcher or Engraver Extractive (e.g., mine machines, drills) Explosives Worker Farmworker Fishing & Hunting Floor Finisher Food Processor Food Service Furniture Finisher Grounds Maintenance Worker Hairdresser, Hair Stylist &/or Cosmetologist Health Care Worker Home Care Taker Installation, Maintenance & Repair Worker Jeweler Logging, Forest & Conservation Worker Machinist Material Moving Metalworking & Plasticworking Miner Miscellaneous Production Worker Manicurist Mortician and Embalmer Office Worker Painter Pest Control Worker Petroleum worker Photo processing, photographer Physician, Anesthesiologists Pilot Police or Sheriff Patrol Officer Printing Worker Retired Roofer Textile, Apparel & Furnishing Worker Utilities & Transportation Worker Welder including soldering & brazing Woodworker Other: List: ____________________________ None
Demographic Questions Script: The next questions are about your own qualities and will help us compare your test results. Surveyor, please indicate whether the person is a male or female. If this questionnaire is for a minor child, be sure to ask their gender.
* What is your sex?	M						F
Date of Birth: dd/mm/yr(xxxx)
* Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)	No, not of Hispanic, Latino/a, or Spanish origin	Yes, Mexican, Mexican American, Chicano/a				Yes, Puerto Rican		Yes, Cuban			Yes, Another Hispanic, Latino, or Spanish origin
* What is your race?? (One or more categories may be selected)	White				Black or African American				American Indian or Alaskan Native
	Asian Indian		Chinese				Filipino			Japanese
	Korean		Vietnamese				Other Asian
	Native Hawaiian		Guamanian or Chamorro				Samoan			Other Pacific Islander
What is your current height?	Ft						in
What is your current weight?	lbs
(If female) Are you pregnant? If yes, in what month of pregnancy?	No						Yes: 0-3 4-6 7-9
* Are you deaf or do you have serious difficulty hearing?	Yes						No
* Are you blind or do you have any serious difficulty seeing, even when wearing glasses?	Yes						No
* Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old and older)	Yes						No
* Do you have serious difficulty walking or climbing stairs? (5 years old and older)	Yes						No
* Do you have difficulty dressing or bathing? (5 years old and older)	Yes						No
* Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (15 years old and older)	Yes						No
Household Characteristics Script: The next set of questions is about the number of people in the household and how long you have lived here.
How many people live here fulltime since (INSERT TIMEFRAME), including yourself? (# People in Household)
Are there any children under the age of 18 who live in the household? [if NO skip the next questions]	Yes						No
How many children are between the ages of 0-6 years old?
How many children are between the ages of 7-12 years old?
How many children are between the ages of 13-18 years old?
Do they play or ride bikes in bare soil?	Never Do This		Seldom Do This				Sometime Do This			Always Do This
If there are children who regularly (Choose a timeframe: daily/weekly) visit the household, what are the ages of children under 18?
Please estimate to the nearest hour approximately how long each person was present in the home in the last (INSERT TIMEFRAME).	Person 1			Person 2					Person 3
	Person 4			Person 5					Person 6

Exposure Location Note to Surveyor: If the potential exposure location is different than the household address, ask the following questions. Also fill in the exposure location by address, long/lat, or some other way.
Did the potential exposure take place away from home?	Yes			No
If yes, where? (Building Name)
(Room Number)
(Exposure Location- Street Address)
(Street Address 2 for intersections)
(City)
(State)
(Zip Code)
How long have you been visiting or going to the (Fill in Location Name)?	mm/year
When was the last time you were at the (Fill in Location Name)?	mm/dd/year
What do you do or were you doing at the (Fill in Location Name) exposure location (for example, work, hunt or fish, etc.)?
Exposure Location Information from ATSDR’s Rapid Response Registry
At the time of the event on [specify day and time], what address were you [was the registrant] at or what was the name of the building or intersection closest to you [the registrant]?
Were you [was the registrant] present at [the event site]?	Yes	No		DK		Refused
If yes, were you [was the registrant]:	inside a building or structure inside a car or other vehicle	Outside		Other		Specify:
	Don’t Know (DK)	Refused
Did you [the registrant] get an injury or any illness as a result of the event?	Yes	No		DK		Refused
If Yes, what illness or injury did you [the registrant] get? (List all)				DK		Refused
Before the event, did you [the registrant] have a:	Chronic illness		Physical Disability		Other Disability
	Unsure		Refused
Are you [is the registrant] pregnant? [or "Were you (was the registrant) pregnant at the time of the event?"]	Yes	No		DK		Refused
Are you [is the registrant] in need of:	Medications/ supplies		Medical care		Utilities
	Food		Shelter		DK
	Refused

Indoor Air Script: These questions will help us determine the possible sources of air pollutants in your household and any symptoms or conditions that would make breathing pollutants more harmful to you.
Time Indoors
How many hours per day do you spend inside your home in a usual weekday? (24 hours is one day)	Less than 8 hours Between 8 and 14 hours Between 15 and 24 hours
How many hours per day do you spend inside your home in a usual weekend? (24 hours is one day)	Less than 8 hours Between 8 and 14 hours Between 15 and 24 hours
How many fewer hours do you spend indoors during the warmer months? (How much additional time are you outside)?	Same Between 1 and 3 more hours 4 or more hours
How many hours per day did you spend inside the home [INSERT TIMFRAME]? (24 hours is one day)
How many hours per day did you spend away from home [INSERT TIMFRAME]? (24 hours is one day)?
Did you leave you window open [add timeframe]?
Confounders and Other Sources Script: These questions relate to other things that may trigger symptoms similar to air pollutants. Note to surveyor: Confounders to symptoms are listed here. Chemical specific confounders are listed under the chemical you are investigating.
Are there any smokers in the household (not including you) [if ‘no’ skip]?	Yes				No
Do you currently smoke?	Yes		No				Refused
If you smoke, how long ago did you smoke your last cigarette?
[If there are any smokers in the house] How many people smoke?
How many cigarettes per day are usually smoked anywhere inside the home by anyone? (20 in a pack)	none	1-5		6-10		11-20		>20
How many cigars per day are usually smoked anywhere inside the home by anyone?	None		1				>1
In the last three days, did {you/she/he} spend 10 or more minutes near a person who was smoking a cigarette, cigar, or pipe?	Yes		No				DK
How many pipes per day are usually smoked anywhere inside the home by anyone?	None		1				>1
Do you have any pets?	Yes				No
What types of indoor pets do you have in your home?	Dog				Cat
	Rodents: hamster, mice, rat, gerbil, guinea pig				Rabbit
	Ferret				Other: list
Fuels Used Indoors
Do you use any of the following in your home?	Natural gas used for heating Natural gas used for cooking Propane gas used for heating Propane gas used for cooking Kerosene Coal used for heating Coal used for cooking Wood Burning Stove used for heating Wood Burning Fireplace used for heating Wood Burning Fireplace used for cooking Gasoline Solar Artificial Logs (disposable store bought e.g., Duraflame) None If ‘none’ skip next two questions.
During which month do you (or does the building) usually start using those fuels?	Start Month: Jan Feb March April May June July August Sept Oct Nov Dec
During which month do you usually (or the building) stop using those fuels?	Stop Month: Jan Feb March April May June July August Sept Oct Nov Dec

Symptoms/Conditions

Script: Individuals with certain conditions may be more sensitive to the effects of chemicals. I would like to ask you questions about your health.

Is anyone in the household pregnant?

Yes

No

DK

If yes, in what month of pregnancy?

0-3

4-6

7-9

Adults

Have you or any other adult household members ever been told by a health care professional that you/they have a chronic heart or lung conditions, such as coronary artery disease, angina (pain in the heart), asthma, or emphysema? [if ‘no’ go to the next section]

Yes

No

Refused

Do you/they currently have that condition?

Yes

No

Don’t Know

If yes, please describe the health condition(s).

Are there any adults with chronic heart or lung conditions, such as coronary artery disease, asthma or emphysema?

No

Yes

DK

Are there times when your condition(s) gets worse? (e.g., night, day weekend, weekday)

Yes

When?

No

Are there any places when your condition(s) get worse? (e.g., home, work, school)

Yes

When?

No

Are there any seasons when your condition(s) get worse? (e.g., spring, summer, fall, winter)

Yes

When?

No

Children

Are there any children (under the age of 18 years old) with chronic heart or lung conditions, such as congenital heart disease, asthma or cystic fibrosis?

Yes

No

Don’t Know

If yes, what are the ages of these children?

Please describe the condition(s).

Are there times when your condition(s) gets worse? (e.g., night, day weekend, weekday)

Yes

When?

No

Are there any places when your condition(s) get worse? (e.g., home, work, school)

Yes

When?

No

Are there any seasons when your condition(s) get worse? (e.g., spring, summer, fall, winter)

Yes

When?

No

Odors/Fumes

Have you or your household members of any age noticed odors or fumes in your home or in common areas where you spend the most time (bedroom, living room, kitchen)?

Yes

No

DK

If yes, please describe the odors/fumes, as well as their location, when they occur (times of the day, days of the week, seasons of the year), and duration:

Describe odor:

When:

Time of day

Day of week

Season

How long:

Have you been told you have the following:

Condition	Yes/No	Were you told you had this by a doctor or nurse? Yes/No	How old were you when a doctor or nurse first told you?
Asthma, allergies
Chronic bronchitis or emphysema?
Angina

Attributes of the Structure or Home The following questions are about the qualities and characteristics of your home.
Do you live in an:	Apartment		Single Family Home		Townhouse or Condominium
	Mobile Home		Other (Specify)
If you live in an apartment, town home, or any multistory structure, how many floors are there?	Number of floors in building _____
If you live in an apartment, town home, or any multistory structure, what floor do you live on?	Participant floor number _____
About when was the building built?	2000-present 1990-1999 1985-1989 1980-1984 1970-1979 1960-1969 1950-1959 1940-1949 1939 or earlier DK
What is the condition of your home or building?	Good		Fair		Poor
Is the home or building built on a slab?	Yes		No		DK
Does the home or building have a basement?	Yes		No		DK
Does the home or building have a crawlspace?	Yes		No		DK
Does the home or building have an attached garage?	Yes		No		DK
Do the windows (e.g., sills) have peeling paint?	Yes		No		DK
Is there peeling paint in other places?	Yes		No		DK
Do you currently have mold in your home on an area greater than the size of a dollar bill?	Yes	No		DK		Refused
Do you have a woodstove or fireplace?	Yes			No
Does smoke enter the room when you use it?	No		Yes		DK
Are there any chemicals or open containers stored in or near the living spaces of your home?	Yes		No		DK
Do you use pesticides in your home?	Yes		No		DK
Other
Is there anything you want us to know that we did not ask about?

Water Script: These questions will help us determine the overall quality of your water as it relates to your exposure or use.
What is your main source of drinking water in your home or building?	City or county (public) Private well Spring Pond Cistern Community well Bottled Other Specify: __________ Don’t know
(If a water company) What is the name of the water company that provided the water (the place where you send in your water bill)? (Interviewer may want to get the usage off the water bill)
If you have a private well, has it been tested?	Yes		No		DK
If ‘yes’ do you know the date it was tested, who did the testing, whether it was tested for bacterial and/or chemical contamination, and the results?	Date: Company: Bacteria / Chemical Results:
What is your main source of water used for cooking?	City or county (public) Private well Spring Pond Cistern Community well Bottled Other Specify: ____________ Don’t know
What is your main source of water for bathing and showering?	City or county Private well Spring Pond Cistern Community well Bottled Other Specify: ______________ Don’t know
Surveyor, the next three questions are for suspect Volatile Organic Compounds (VOCs) in water:
In the last three days [or INSERT TIMEFRAME], did {you/she/he} take a hot shower or bath for five minutes or longer?	Yes		No		DK
How long ago, in hours, has it been since {your/her/his} last shower or hot bath?
Do you limit time showering and bathing?	Never		Sometimes		Always
Do you shower or bathe in cool water?	Never		Sometimes		Always
Do you limit steam exposure (e.g., from dishwasher, boiling)?	Never		Sometimes		Always
What is your main source of water for pools and hot tubs?	City or county Private well Spring Pond Cistern Community well Bottled Other Specify: ______________ Don’t know
List all of the water treatment devices for your drinking water or water used for mixing drinks (e.g., formula, juices).	None Charcoal Filter/Granular Activated Carbon (GAC) Ceramic Filter Reverse Osmosis Water Softener Boil Water Distillation Aerator Water Filter System (Brita, Pur, etc)
List all of the water treatment devices for your water used for cooking.	None Charcoal Filter/GAC Ceramic Filter Reverse Osmosis Water Softener Boil Water Distillation Aerator Water Filter System (Brita, Pur, etc)
List all of the water treatment devices for your bathing and showering water.	None Charcoal Filter/GAC Ceramic Filter Reverse Osmosis Water Softener Boil Water Distillation Aerator Water Filter System (Brita, Pur, etc)
Do you use water filters in your home?	Yes		No		DK
If you have filters, do you regularly replace and maintain filters?	Never	Sometimes		Always		DK
Do you follow drinking water recommendations?	Never	Sometimes		Always		DK
Plumbing Do you have copper pipes?	Yes		No		DK
Does your plumbing have lead solder?	Yes		No		DK

Soils Script - If chemicals are in the soils, you can get them on your skin by gardening, playing, touching your pets, walking barefoot on exposed dirt (no grass, mulch, etc). If the question is not applicable to you , please answer "Never Do This."
Soils Information –Contact
Did you bring home [LIST soil, products, etc] from [LIST LOCATION].	Yes			No
How often do you work in soil IN YOUR YARD (e.g., gardening, digging, building, repairing)?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
If "Never Do This", skip next 5 questions
If so, how frequently do you work in soil in your yard?	Daily		Weekly		Monthly
How often do you use gloves and protective clothing when you work in soil? (e.g. working, playing outdoors, gardening, yardwork)	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
How often do you change clothes immediately after outdoor activity (e.g. working, playing outdoors, gardening, yard work)	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
How often do you wash hands, face, and/ or other exposed skin immediately after outdoor activity (e.g., working, playing outdoors, gardening, yard work)?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
How often do you wash dirty clothes immediately after wear (e.g., work clothes, yard work clothes)?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
Soil Information (Tracking inside home)
How often do you remove shoes before entering your home?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
How often do you cover bare soils with turf or mulch?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
How often do you wet-down disturbed soils (e.g. gardening, digging, building)?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
When you go outside, how often do you have contact with dirt without shoes?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
Pets (Tracking dirt inside and dander)
Do you have any pets?	Yes			No
What types of indoor pets do you have in your home?	Dog	Cat		Rodents: (hamster, mice, rat, gerbil, guinea pig)		Rabbit
	Ferret	Other:
When your pets go outdoors, how often do they track dirt into the house?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
List the number of indoor pets that regularly go outdoors.
Note to surveyor - The pets questions can be asked of one person in the household and don't have to be repeated for each person.
House Cleaning Frequency
Script –This next set of questions is about the cleaning habits in your home by you or someone else.
Note to surveyor: The home cleaning questions can be asked of one person in the household and don't have to be repeated for each person.
How often does anyone wet mop your home?	Twice a week	Once a week		Less than once a month		Never
How often does anyone dry dust your home?	Twice a week	Once a week		Less than once a month		Never
How often does anyone broom sweep your home?	Twice a week	Once a week		Less than once a month		Never
How often does anyone vacuum your home? [if never go to next section]	Twice a week	Once a week		Less than once a month		Never
Does your vacuum have a bag?	Yes			No
Does your vacuum have a high efficiency particulate air (HEPA) filter?	Yes		No		Don’t Know
Was (INSERT TYPE OF CLEANING, OR SAY ANY CLEANING) done in rooms where the samplers were placed?	Yes			No
If yes, what type of cleaning?	Vacuum		Damp mop		Wet mop
	Dry mop or dust		Sweep		Other:
If you currently have children ≤ 18 in your home, please respond to the following statements. If not, please skip to the next section.
Do you keep children from playing, biking, or doing other activities in areas with possible soil contamination?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
Do you keep children from eating dirt?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This
Do you keep children from putting their fingers and hands in their mouths?	Never Do This	Seldom Do This		Sometimes Do This		Always Do This

Garden Script: The next questions are about your contact with fresh fruits and /or vegetables
Does anyone, including you or a lawn service, use chemicals on your lawn or garden?	Yes		No		Don’t know
Do you or your neighbor grow fruits and vegetables in the yard?	Yes			No
What vegetables/fruits do you grow and eat from you or your neighbor’s garden?
When was the last time you ate that vegetable and/or fruit?	Days	Weeks		Months		Years ago
When you eat those fruits and/or vegetables, how often do you eat them?	Daily		Weekly		Monthly
How often do you wash the vegetables and/or fruit before you eat them?	Never		Sometimes		Always
How often do you wash the vegetables and /or fruit before you cook them?	Never		Sometimes		Always
(Note to surveyor: Process can include pressure cooking (can or bag, hot water (can or bag), freezing, or drying)
Do you process your fruit and vegetables or your neighbor’s? [if 'no' go to next section]	Yes		No		Don’t Know
When was the last time you ate your processed fruit or vegetables?	Days		Weeks		Months
How often do you or your family eat the vegetables and/or fruit you processed from your garden?	Daily		Weekly		Monthly
How often do you or your family eat the vegetables and/or fruit you processed from your neighbor’s garden?	Daily		Weekly		Monthly

Foods
Fish Script: These questions will help us determine if eating locally caught fish may increase your contact with chemicals. First for the following questions, when I say “fish”, I mean any type of seafood, including shellfish, squid, crab, sea urchins or seaweed
Does anyone in your household currently catch fish (of any kind) from [LIST WATERBODY]?	Yes	No		DK
Does anyone in your household eat the fish caught from [LIST WATERBODY]?	Yes	No		DK
How long have you eaten fish? (RECORD IN YEARS)
Script: When I say “fish meals”, I mean any meal you had which consisted of the entire fish or parts of fish
What kind of fish and how many fish meals have you eaten in [INSERT TIME FRAME OR USE the last 30 days]? (RECORD NUMBER for each)
How many ounces of fish do you usually eat in one meal? (Surveyor: USE A MODEL FOR SIZE IF POSSIBLE)	1-4oz	5-8oz		>8oz
What is your primary source of fish? In other words, where do you usually get the fish that you eat? Do you… (SURVEYOR: READ LIST. ONE ANSWER ONLY)	Catch fish yourself or get it from a household member Purchase from a roadside vendor or flea market Purchase from a fisherman’s co-op Purchase from a supermarket Purchase from a restaurant Receive from family and friends Other (SPECIFY
In the last 30 days, how often did you eat fish caught from LIST WATERBODY(IES) OF INTEREST?
For (AREAS MENTIONED ABOVE), what type(s) of fish did you USUALLY catch, take home and eat?
Did you eat fish within the last [INSERT TIME FRAME OR USE seven days]?	Yes		No
Where did you get the fish that you ate within the last [INSERT TIME FRAME OR USE seven days]? In other words, where do you usually get the fish that you eat? Do you… (READ, CIRCLE ALL THAT APPLY)	Catch fish yourself or get it from a household member Purchase from a roadside vendor or flea market Purchase from a fisherman’s co-op Purchase from a supermarket Purchase from a restaurant Receive from family and friends Other (SPECIFY)
(FOR EACH FISH EATEN) Which parts of this fish do you usually eat? (CHECK ALL THAT APPLY)	Whole Filet Head Bones Intestines Eyes Skin Fish eggs (roe)
FOR EACH FISH EATEN) How do you usually prepare this fish? Do you skin it, trim the fat, gut it, a combination of, or some other way?	Skinning Trimming fat Gutting Combination Other
What is your PRIMARY cooking method for this fish?	Raw Pan Fried Deep Fried Boiled/ Stewed Grilled Baked Other
Communication/Education
Before taking this survey, were you aware of the LIST ADVISORY that has been issued for the LIST AREA?	Yes		No

Which of these information sources made you aware of the ADVISORY OR WARNING? (CHECK ALL THAT APPLY)	A story in the newspaper A print advertisement in the newspaper Television broadcast Radio talk show or radio news Posted signs and notices Meeting Family and friends Church announcement/church bulletin or newspaper Word of mouth Other
Since you learned about the ADVISORY OR WARNING, have you made any changes in either the way you eat the fish you catch or in your fishing habits?	No, I have not made any changes in my fishing or eating habits.
	Yes
If ‘yes’, which of these apply to you?	I no longer eat any fish from the Advisory or Warning area I eat less fish now than before the Advisory or Warning. I eat more fish now because I can choose fish from areas outside the Advisory or Warning area. I have reduced the size of my fish meal portions. I have changed the way I prepare locally caught fish before I eat it. I have changed the way I cook locally caught fish before I eat it. I have changed my fishing locations. I have changed the species I fish for because of the Advisory or Warning. Other
How would you like to be informed of any future advisories or notices?	Newspaper article Newspaper advertisement Television news broadcast Radio talk shows/news Posted signs and notices in areas that you fish Meetings Family and friends Church announcement/church newspaper Word of mouth Other

Domestic Animals Script: These questions will help us determine if eating locally raised domestic animals may increase your contact with chemicals. First for the following questions, domestic animals are defined as locally raised animals that are used as a source of meat (such as cattle or chicken). Also the products of these domesticated animals such as milk or eggs are to be included in this survey
Do you currently eat locally raised domestic animals (of any kind)?	Yes			No
If yes, what type and how are they used for food?	Domestic Food # meals Source Animal in last 30 (see list) days _____________________________________________________ Cattle: Beef Milk* **Organs Chicken: Meat Eggs Organs Goat: Meat Milk* Organs Sheep/Lamb: Meat Milk* Organs Pigs/Boar: Meat Organs Turkey: Meat Eggs Organs Ostrich: Meat Eggs Organs Other: List * Milk and milk products including milk, butter, cheese, yogurt, etc) **Indicate if the milk products are pasteurized. Source List: Where do you usually get the domestic animals that you eat? Do you… (READ LIST. ONE ANSWER ONLY) Raise domestic animals yourself or get it from a household member Purchase from a roadside vendor or flea market Purchase from a domestic animal co-op Purchase from a supermarket Purchase from a restaurant Receive from family and friends 7. Other (SPECIFY)
Game Script: Game refers to wild animals such as deer which are hunted and used as a source of food.
Do you currently eat game (of any kind)?		No, NEVER I do not currently eat game, nor have I ever eaten game.	No, PREVIOUS but I have previously eaten game.			Yes
How long have you eaten game? (RECORD IN YEARS)
Do you hunt or is game given to you to eat?		Yes			No
Where do you hunt? (RECORD LOCATION)

Check the game you consume and list how often (weekly, monthly, yearly) and the primary place you get the game (READ LIST. ONE ANSWER ONLY):

Game Frequency Source (Weekly, Monthly, Yearly) (see list) ____________________________________________ Deer Rabbit Quail Duck Dove Turkeys Elk Caribou Alligator Other: List Where do you usually get the game that you eat? Do you… Hunt game yourself or get it from a household member Purchase from a roadside vendor or flea market Purchase from a game co-op Purchase from a supermarket Purchase from a restaurant Receive from family and friends Other (SPECIFY)

Confounders/Other Possible Sources of Exposure Questions Script: For the next set of questions, we will be asking you about other ways or places you may have come in contact with chemicals.
Occupational Questions Script: Answer the following questions about the kinds of jobs you have had.
What is the name of your current employer (s)?	Job1				Job2			Job3
Which best describes your current employment status?	Employed for wages			Self-employed			Out of work for more than 1 year			Out of work for less than 1 year
	A Homemaker			A Student			Retired			Unable to Work
At your present work: What best describes the type of work you are doing (at Job 1, Job2, Job3 etc.)? (Note to surveyor: This is an example of an industry or occupation list. It should be edited to only include jobs of interest to your investigation (e.g., jobs that may include chemical use similar to what you are investigating. If you want to include an exhaustive list of occupations or industries, you can use the U.S. Census list found at http://www.census.gov/hhes/www/ioindex/overview.html If you want to narrow the list to jobs or industries with chemical of interest, consider searching “agents” @ http://hazmap.nlm.nih.gov/, then look at processes, industries, and activities with risk of exposure. You can also search it backward when you know a job and it will tell you the hazards associated with that job.)	Animal Control Worker, Animal Scientist, Veterinarian Airport or Aircraft Worker Arts & Media Assemblers & Fabricator Car Repair, Mechanic Chemical Industry Worker (mixer, processor, researcher) Child Care Worker Cleaning homes or offices Construction Crop & Livestock Production Dentist, Dental Hygienist Detective and Criminal Investigator Disabled & stay at home Dry Cleaning Worker Fire Fighter Electrician, Electrical worker Engineering, Sciences & Education Equipment Operator Etcher or Engraver Extractive (e.g., mine machines, drills) Explosives Worker Farmworker Fishing & Hunting Floor Finisher Food Processor Food Service Furniture Finisher Grounds Maintenance Worker Hairdresser, Hair Stylist &/or Cosmetologist Health Care Worker Home Care Taker Installation, Maintenance & Repair Worker Jeweler Logging, Forest & Conservation Worker Machinist Material Moving Metalworking & Plasticworking Miner Miscellaneous Production Worker Manicurist Mortician and Embalmer Office Worker Painter Pest Control Worker Petroleum worker Photo processing, photographer Physician, Anesthesiologists Pilot Police or Sheriff Patrol Officer Printing Worker Retired Roofer Textile, Apparel & Furnishing Worker Utilities & Transportation Worker Welder including soldering & brazing Woodworker Other: List: ____________________________ None
What is your current job title?	Job1				Job2			Job3
What are your main job tasks?	Job1				Job2			Job3
When did you start to work for your current employer(s)? (Note: try to get month and year or at least year) or “current job” )	mm/dd/year
For the following questions, “contact” means touching, breathing, or eating/ ingesting/swallowing
Do you have contact with harmful chemicals, physical debris, dusts or mists, or hazardous powders at your current job?	Yes Job1 Job2 Job3				No			DK
If yes to the above question, please describe the hazard (Surveyor, list the hazards and circle the response).	Solvents	Breathing			Physical	Dusts		Fuels	Breathing
		Touching				Gas			Touching
		Swallowing				Liquid			Swallowing
		Other (list)				Mists			Other (list)
	Asbestos				Silica			Lead
Have you or could you have contact with radiation at your job?	Yes Describe:				No			DK
Have you or could you have contact with [INSERT CHEMICAL OR COMPOUNDS OF INTEREST] at your job (e.g., lead, asbestos, silica)?	Yes Job1 Job2 Job3 Describe:				No			DK
Are you required to wear protective equipment at your current job? [if ‘no’ skip to the next section]	Yes						No
Do you wear protective equipment such as gloves, dust mask or respirator, hood, etc at work?	Always				Sometimes			Never
What type of equipment was worn?	Gloves		Always		Dust Mask	Always		Respirator	Always
			Sometime			Sometime			Sometime
			Never			Never			Never
	Coverall/ Clothing		Always		Eye Protection	Always		Hood	Always
			Sometime			Sometime			Sometime
			Never			Never			Never
Do you wear your work clothes home?	Always				Sometimes			Never
Do you wear your work shoes home?	Always				Sometimes			Never
Do you shower and/or change clothes before coming home from work?	Always				Sometimes			Never
Have you ever been off work from your current job for more than a day because of an illness or injury related to your work?	Yes Describe: When:						No

At your past work: What jobs or industries have you worked in the past (Surveyor: insert 1, 2, 5, 10 or other timeframe of interest) year(s)? Note when (approximate year or timeframe) and approximately how long (months or years) by each. Example: Welding and soldering metals, 1989- Construction, 1987, years	Job		Time Period		Months
					Years
					Months
					Years
					Months
					Years
What is the longest job held? When? How long?
Have you ever been in the military?	Yes Main Job Tasks: When: How long:			No
Have you ever worked on a farm or done seasonal farm work?	Yes Main Job Tasks: Describe: When: How long:			No
At your past work, have you ever worked at a facility that [INSERT (processed, machined, used)] [INSERT CHEMICAL OR COMPOUND]?	Yes Job Tasks: Describe: Job Title: When: How Long: or Year Began: Year End:			No
Have you ever been off work from a past job for more than a day because of an illness or injury related to your work?	Yes Describe: When:			No
Have you ever changed jobs or work assignments because of work-related health problems or injuries?	Yes Describe: When:			No
Occupational/Take Home Questions Script: Answer the following questions about the jobs people in or visiting the household have had.
Has anyone in the household worked in [list industry]? Surveyor: If more than one person has contact with chemicals, ask these questions for each separately.	Yes			No
Did that person come home from work without showering?	Always	Sometimes		Never		DK
If they worked in the past: Did that person wear work clothing home after working?	Always	Sometimes		Never		DK
Did that person wear protective equipment such as gloves, dust mask or respirator, hood, etc at work?	Always	Sometimes		Never		DK
Did they wear their work shoes home?	Always	Sometimes		Never		DK
If they are currently working: Does that person wear work clothing home after working?	Always	Sometimes		Never		DK
Do they wear their work shoes home?	Always	Sometimes		Never		DK
Does that person shower before they come home from work?	Always	Sometimes		Never		DK
Does that person wear protective equipment such as gloves, masks, hood, etc at work?	Always	Sometimes		Never		DK

Hobbies Questions Script: A hobby is considered an activity or interest pursued outside one’s regular occupation and engaged in primarily for enjoyment. Answer the following questions about your hobbies and activities at home.

What hobbies do you or your household members engage in AT home? (List hobbies (excluding sports). Example: woodworking, stained glass, etc.) (Note to surveyor: If you want to narrow the list to hobbies with chemical of interest, consider searching the tab “ingredients” @ http://hpd.nlm.nih.gov/index.htm , then list the chemical and it will provide a list of products that contain it. You can also search “products” and choose “arts and crafts” to display the chemicals associated with the hobby.)

Batik printing Candle-making Ceramics making Dye Use Electronics Epoxy Use Enameling Fishing gear (making) sinkers, etc Glassblowing Home remodeling Intalagio printing Jewelry making Leather crafting Lithography printing Lost wax casting Metal work Model making Painting Preparing, stuffing, and mounting animal skins (taxidermy) Soap making Staining Sculpturing plastics Sculpturing stone containing crystalline silica, e.g., granite Stained glass making Woodworking None

What hobbies do you or your household members engage in AWAY from home? (List hobbies (excluding sports). Example: woodworking, stained glass, etc.)

Batik printing Candle-making Ceramics making Dye Use Electronics Epoxy Use Enameling Fishing gear (making) sinkers, etc Glassblowing Home remodeling Intalagio printing Jewelry making Leather crafting Lithography printing Lost wax casting Metal work Model making Painting Preparing, stuffing, and mounting animal skins (taxidermy) Soap making Staining Sculpturing plastics Sculpturing stone containing crystalline silica, e.g., granite Stained glass making Woodworking None

Do you burn, solder, or melt any products?

Yes

No

If yes, please describe:

On average, for the past month, how many days did you use lead solder to join pieces of stained glass?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

On average, for the past month, how many days did you use lead based oil paint to paint pictures or jewelry?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

Do you use any alternative healing or cultural practices?

Yes Describe:

No

Household Chemical Uses and House Construction Questions Script: To the best of your ability, answer the following questions about the household products you are using and/or that were used in the construction of your home.

Fuels Have you recently (within the past {X} days) used or been near fuels?

Yes

No

Is any gasoline, diesel, fuel oils, or kerosene being stored in any room or basement of your home or in an attached garage or carport?

Yes

No

Are any devices with gasoline or diesel engines such as lawn mowers being stored in any room or basement of your home or in an attached garage or carport?

Yes

No

In the last three days – today, yesterday, or the day before yesterday In the last three days [or INSERT TIMEFRAME], did {you/she/he} pump gas into a car or another gasoline/diesel powered engine {yourself/herself/himself}?

Yes

No

How long ago, in hours, did {you/she/he} pump gas?

When did you last ride in a gasoline/diesel powered vehicle?

In the past three days [or INSERT TIMEFRAME], have you breathed fumes from car, lawn mower or any other gasoline or diesel powered engine?

Yes

No

How long ago, in hours, did {you/she/he} breathe fumes?

Landscape or Yard Products Have you recently (within the last {X} days or weeks) used any landscape or yard products such as fertilizer, lawn care, swimming pool products, etc?

Yes

No

If so, list the commercial or brand name of those

Cleaning Products Have you recently (within the last{ X} days or weeks) used any cleaning products inside the home? Example: air fresheners, bleach, toilet bowl cleaner, etc

Yes

No

If so, list the commercial or brand name of those.

Yesterday or {INSERT TIMEFRAME}, did any activities in the home or elsewhere involve working with or being near stain or spot removers?

Yes

No

If so, list the commercial or brand name of those.

Auto Products Have you recently (within the last{ X } days or weeks) used any auto products such as brake fluid, de-icer, lubricant, sealant, etc?

Yes

No

If so, list the commercial or brand name of those.

Home Maintenance and Renovations Have you recently (within the last {X} days or weeks) used any home maintenance products such as caulk, grout, insulation, paint, putty stain, etc?

Yes

No

If so, list the commercial or brand name of those.

Are any paints or varnishes being stored in any room or basement or your home or in an attached garage or carport?

Yes

No

Are any woodworking solvents, paint stripping fluids or adhesives stored in any room or basement of your home or in an attached garage, or carport?

Yes

No

On average, for the past month, how many days did you paint walls, furniture, cars, or other objects?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

On average, for the past month, how many days did you use chemical paint strippers?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

On average, for the past month, how many days did you remove paint by other methods such as scraping, heat gun, or sanding?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

In the {last 6 months or INSERT TIMEFRAME}, have you or anyone else renovated your home in any way? This would include indoor painting, refinishing floors, adding rooms to the house or laying new carpet.

Yes

No

In the{last 6 months or INSERT TIMEFRAME}, was any indoor painting done?

Yes

No

In the{last 6 months or INSERT TIMEFRAME}, have the floors in your home been refinished?

Yes

No

In the{last 6 months or INSERT TIMEFRAME}, have you had new carpet installed?

Yes

No

If you have had new carpet, was glue used or was it tacked down?

Glue

Tacked

Other

DK

In the{last 6 months or INSERT TIMEFRAME}, were additions constructed to the house or building?

Yes

No

Pesticides, Herbicides Have you recently (within the last {X} days or weeks) used any pesticides including animal repellant, fungicide, herbicide, insecticide, etc to get rid of insects, rodents or other pests?

Yes

No

Was that done:

Inside

Outside

Both

If so, list the commercial or brand name of those

How many times in the (insert time period) were pesticides applied by a PROFESSIONAL?

1-2

3-5

6-9

10+

How many times in the last (insert time period) did you PERSONALLY apply pesticides?

1-2

3-5

6-9

10+

In the past month, were any chemicals used to treat this home to control fleas, roaches, ants, termites, or other insects?

Yes

No

DK

Pet Products Have you recently (within the last {X} days or weeks) used any pet care products such as flea & tick control, litter/stain/odor remover?

Yes

No

If so, list the commercial or brand name of those.

Arts and Crafts Have you recently (within the last {X} days or weeks) used any arts and crafts products such as adhesive, glaze, glue, primer, varnish, etc?

Yes

No

If so, list the commercial or brand name of those.

Drinking Water Have you had your drinking water tested?

Yes

No

DK

If so, what did the results show?

On average, for the past month, how many days did you use lead solder to solder pipes, do electric repairs?

Never 1-3 days per month 1-2 days per week 3-6 days per week Daily Don’t know

Lifestyle Questions Script: Sometimes our lifestyle can contribute to an increase or decrease in the chemical levels found our body. Answer the following questions about lifestyle.

Have you had a meal high in fat (fried fish, hamburgers, etc) in the X days?

Yes

No

Medicine Questions Script: Some medicines may contain small amounts of chemicals and can affect your test results. Please answer the following questions about medicines you are taking.

Please list the prescription medications you now take.

Please list any over the counter medications such as vitamins, supplements (herbal and nutritional), acetaminophen (Tylenol) taken on a daily basis.

For medicines you do not take frequently (in the past few days), when was the last time you took that medicine?

Frequency of Contact Questions Script: Script - You may have had contact with chemicals from more than one place. Please answer these questions on where you believe you had the most contact with chemicals. "Contact" means breathing, touching, swallowing/eating/ingesting. "Chemicals" means (dust, paints, glues, cleaning fluids, pesticides, weed killer, etc.)

Answer the following questions on a scale of 1 to 4, 1 meaning "less" and 4 meaning "more." Where do you believe you have more frequent contact with chemicals?

Work

Less

1

2

3

4

More

Hobbies

1

2

3

4

Home

1

2

3

4

Lifestyle

1

2

3

4

Foods

1

2

3

4

Answer the following questions on a scale of 1 to 4, 1 meaning "less" and 4 meaning "more." Where do you believe you have the most amount of contact with chemicals?	Work	Less	1	2	3	4	More
	Hobbies		1	2	3	4
	Home		1	2	3	4
	Lifestyle		1	2	3	4
	Foods		1	2	3	4

Confounders/Other Possible Sources of Exposure Questions Chemical-Specific Set
Food, Drink, Medicines Script: Sometimes chemicals are naturally found, can accumulate in, or are added to foods. Answer the following questions about food, drinks, or medicines you have had recently.
Arsenic
Have you eaten seafood (finfish, shellfish like oysters, crabs. mussels, lobster, or other like octopus, squid, etc) in the past 3-4 days?	Yes						No
Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days? (Note: Asian herbal remedy Kushtay may contain Ar)	Yes If yes, please list them:						No
Have you eaten [INSERT FOOD] in the past [INSERT TIMEFRAME]?	Yes If yes, please list them:						No
Mercury
When was the last time you ate fish?	Days			Weeks					Months
Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days?	Yes If yes, please list them:						No
Do you or your family members use mercury for medicinal or ceremonial purposes?	Yes						No
PCBs
When was the last time you ate seafood (finfish, shellfish like oysters, crabs. mussels, lobster, or other like octopus, squid, etc)?	Days		Weeks				Months			Years
PAHs
In the last month, have you eaten any food that was grilled, blackened, charred, smoked or roasted through cooking?	Yes						No
How many servings?	1-2	3-5			6-10			11-19			20+
In the last [INSERT TIMEFRAME], have you had any drinks that were roasted through cooking? (e.g., roasted coffee)?	Yes						No
If so, how many servings?	1 to 2	3 to 5			6 to 10			11 to 19			More than 20
Naphthalene
{Do you/Does she/Does he} use toilet bowl deodorizers inside {your/her/his} home? [Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.] [NOTE: Naphthalene is also used for in fungicides, lubricants, explosives, and wood preservatives. There are questions for those under Confounders/Other Possible Sources of Exposure Questions.]	Yes						No
{Do you/Does she/Does he} use moth balls or crystals inside {your/her/his} home?	Yes						No
Fluoride, other Chemicals?
Do you or your family members drink tea?	Yes						No
Lead
Have you eaten candies produced in Mexico in the past 2 months?	Yes						No
Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days? (Note: Bint al Thahab, some calcium supplements, Chinese herbal medicine, surma)	Yes If yes, please list them:						No
Lifestyle Questions Script: Sometimes our lifestyle can contribute to an increase or decrease in the chemical levels found in our body. Answer the following questions about lifestyle.
Cadmium Cadmium is a heavy metal that is found in cigarette smoke, semiconductor manufacturing, welding, battery manufacturing, and metal smelting operations.
Have you or could you have had contact with Cadmium at your job?	Yes						No
Do you smoke cigarettes now?	Yes						No
How often do you smoke cigarettes?	Daily			Weekly					Monthly
How many cigarettes do you smoke per day?	1-5 day		6-10 day				11-20 day			>20
Does anyone smoke cigarettes inside your home including household members and frequent guests?	Yes						No
How often do household members or guests smoke cigarettes in your home?	Daily			Weekly					Monthly
PAHs
Do you smoke cigarettes now?	Yes					No
How often do you smoke cigarettes?	Daily			Weekly					Monthly
How many cigarettes do you smoke per day?	1-5 day		6-10 day				11-20 day			>20
Does anyone smoke cigarettes inside your home including household members and frequent guests?	Yes						No
How often do household members or guests smoke cigarettes in your home?	Daily			Weekly					Monthly
Health Conditions ….may be used for lead, uranium, cadmium, benzene Script: Sometimes a health condition can contribute to an increase or decrease in the chemical levels found in our body. Answer the following questions about your health conditions.
Do you or have you had any of the medical problems below?	Diabetes type I or II Kidney disease High Blood Pressure Anemia, from low iron Bone problems or disease (like osteoporosis or “brittle bones”) Chronic Respiratory Illness such as Asthma and Chronic Obstructive Pulmonary Disease (COPD) Sickle Cell Anemia or Trait G-6-P-D deficiency
If yes, give details
Are there times when your condition gets worse? (e.g., night, day weekend, weekday)	Yes When?						No
Are there any places when your conditions get worse? (e.g., home, work, school)	Yes When?						No
Are there any seasons when your conditions get worse? (e.g., spring, summer, fall, winter)	Yes When?						No

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