Enrollment Survey for Fathers

_{Form Approved:}

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

_{Participant Number: Version 1_}

Navajo Birth Cohort Study

SURVEY FOR FATHERS

The Birth Cohort study is being conducted in response to community questions and concerns about whether exposure to uranium from remaining mining and milling waste is affecting the outcome of pregnancies and/or the development of children on Navajo Nation. The study will provide additional development and environmental evaluations for moms and children. The goal is to ensure that children born on Navajo Nation have all the opportunities for a healthy and successful childhood.

_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

4a. 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}

_{ 1}^st _{to 6}^th _grade

_{ 7}^th _{to 9}^th _grade

 10^th to 12^th grade, no diploma

 High school graduate/GED

 Bachelor’s degree

 Some college, no degree

 Associate degree

 Graduate or professional degree

 Other specify

 Don’t know

 Refused

Public reporting burden of this collection of information is estimated to average 90 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).

_{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

8. What is your best estimate of your total personal income from all sources in the past year (before taxes)? If annual income is 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 ($417 – $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)

 Don’t 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 ($417 – $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)

 Don’t Know

 Refused

HEALTH HISTORY

10. Have you ever been told by a doctor that you have diabetes?

 Yes

 No

 Don’t know

 Refused

11. Have you ever been told by a doctor that you have high blood pressure?

 Yes

 No

 Don’t know

 Refused

12. Have you ever been told by a doctor that you have any autoimmune disorders?

 Yes

 No

 Don’t know

_{ Refused}

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13. Have you had any fertility problems in the past with your partners?

 Yes

 No

 Don’t know

 Refused

14. How many children have you fathered?

| | | Refused

NUMBER

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

 Yes

 No

 Don’t know

 Refused

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

Gender Date of Birth Diagnoses Receiving Care Where

_{Child #1.  Boy Girl / /}

_{Child #2.  Boy Girl / /}

_{Child #3.  Boy Girl / /}

_{Child #4.  Boy Girl / /}

_{Child #5.  Boy Girl / /}

_{Child #6.  Boy Girl / /}

CURRENT MEDICATION AND SUBSTANCE USE

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

Yes →What [prescribed] medications do you take?

_16a.

_16b.

_16c.

_16d.

_{ No}

16e.

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17. Are you currently taking over-the-counter (non-prescription) medications on a daily basis?

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

_17a.

_17b.

_17c.

_17d.

_{ No}

17e.

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

 Yes →What herbal supplements do you take?

_18a.

_18b.

_18c.

_18d.

_{ No}

18e.

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

 Yes →What remedies do you take?

_19a.

_19b.

_19c.

_19d.

_{ No}

19e.

20. Are you currently smoking marijuana?

 Yes

 No

 Refused

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

Yes →What drugs are they?

_21a.

_21b.

_21c.

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_21d.

_{ No}

21e.

22. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctor’s prescription for?

 Yes → 22a. How many times?

 Once or twice

 10 or more times

 Don’t know

_{ Refused}

_{ No}

ALCOHOL USE

23. 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

24. 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

25. 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

26. Do you smoke tobacco only for ceremonial use?

 Yes → [skip to 36]

 No

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

 Yes

 No→ [skip to 36]

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

 Yes

_{ No→ [skip to 36]}

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

 Yes

 No

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

| | |.................................................  Don’t Know

YEARS

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

| | _|

cigarettes/day .........................................  Don’t Know

32. When was your last cigarette?

 Today

 In the past week

 More than a week ago

 More than a month ago

 Before pregnancy

 Don’t know

 Refused

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

 Yes → If Yes: 33a. Did you quit because of your partner’s pregnancy?

 Yes

_{ No}

No

_{34. If you stopped smoking cigarettes and then started smoking again, for how many years did you quit?}

| | |	| | |	 Don’t Know
months quit	years quit

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

 Yes

 No

 Don’t know

_{ Refused}

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.

36. 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}

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37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

 Don’t know

 Refused

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

 Once or more per week

 Once per month

 On occasion

_{ Never}

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44. What is your primary mode of transportation?

 Car

 Bus

 Hitchhiking

 Horseback

 Walking

_{ Other Specify}

HOUSING CHARACTERISTICS

45. What is the location of your home?

[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.]

46. 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

 Don’t know

 Refused

47. 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

 Don’t know

 Refused

48. How long have you lived in this home?

| | |  Weeks

NUMBER .....  Months

..........  Years

..........  Don’t know

..........  Refused

49. 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

 Don’t know

_{ Refused}

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

 Mobile home

 Wood frame

 Stone

 Adobe

 Crawlspace or basement

 Dirt floor

51. 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}

51a. If yes which materials were used  Wood

 Sheet metal

 Metal pipes

 Rocks

 Sand

 Tarps

 Utility poles

 Railroad ties

 Other:

 Don’t know

 Refused

52. 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}

52a.If yes which materials were used  Wood

 Sheet metal

 Metal pipes

 Rocks

 Sand

 Utility poles

 Railroad ties

 Other:

 Don’t know

 Refused

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

| | | NUMBER

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

| | | NUMBER

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

 Electric

 Gas-Natural

 Gas-Propane or LP

 Oil

 Wood

 Kerosene or diesel fuel

 Coal

 Solar energy

 Wind power

 No heating source

 Other specify

 Don’t know

 Refused

55a.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

55b.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

56. 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

 Don’t know

 Refused

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

 Yes

 No

 Don’t know

 Refused

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

 Yes

 No

 Don’t know

_{ Refused}

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59. Since your partner 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

 Don’t know

 Refused

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

 Yes

 No

 Don’t know

 Refused

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

 Dog

 Cat

 Lambs or baby goats

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

 Bird (including chicks)

 Fish or reptile (turtle, snake lizard)

 Other specify

 Don’t know

 Refused

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

 Yes

 No

63. 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 | | |
		| | |
		| | |
		| | |
		| | |
		| | |
		| | |
		| | |

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WATER USAGE

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

 Yes  No  Don’t Know

_{64a.If yes, what is the name of the water system?}

64b.If yes, is this your main source of drinking water?  Yes  No  Don’t Know

65. Do you haul water?  Yes  No  Refused

65a.If you haul water, what type of container do you use to haul water?

 Plastic

 Metal

 Glass

 Wood

 Other Specify

 Don’t know

65b.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

 Don’t know

65c. If yes, in what types of containers do you store this hauled water?

 Plastic

 Metal

 Glass

 Wood

 Concrete

 Other Specify

 Don’t know

65d. 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, don’t do anything to the water

_{ Don’t know}

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65e. How many places do you currently haul water from? | | |

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

66. 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)}

_{| | |}

_{| | |}

_{| | |}

_{| | |}

_{| | |}

_{| | |}

_{| | |}

| | |

67. 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

 Don’t know

 Refused

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

 Hauled water

 Tap or piped in water

 Filtered tap/piped in water

 Bottled water

 Other specify

 Don’t know

_{ Refused}

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FOOD BEHAVIORS

69. Do you eat the meat of the livestock you raise?  Yes  No  Don’t know

_{69a. Where do the livestock graze? (Using map, locate grazing area)}

_{69b. Where do they get water? (Using map, locate wells, springs, ponds, etc.)}

70. 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}

70a. In the last month, have you eaten any food that was blackened, charred, or roasted through cooking?  Yes  No

70b. If yes, how many servings?

 1-2  3-5  6-10  11-19  20+

71. Do you eat the vegetables or fruit you grow? Yes No  Don’t know

72. Do you use the water you haul for the vegetables you grow? Yes No  Don’t know

_{73. 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

74. 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:

 Don’t know

_{ Refused}

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_{OCCUPATIONAL AND ENVIRONMENTAL HISTORY}

_OCCUPATIONAL

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

 Yes

 No

 Refused

If no, skip this section

_{If yes, please answer the following:}

76. 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

 Don’t know

 Refused

76a. If yes, complete the following

Substance Brand/Name Used Indoor Used outdoors How Long

_Pesticide

_Chemicals

_Other

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

Number of Years

 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 ....................................................... | | |}

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

 Pottery ....................................................................... | | |

 Lapidary ..................................................................... | | |

 Weaving ..................................................................... | | |

 Electric/transmission line/Utility crew .......................... | | |

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

 Other Specify | | |

78. 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 | | |

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

 Block or synthetic stones

 Stabilized stones

 Only natural stone

 Don’t know

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

 Yes

 No

 Don’t know

 Refused

_{ENVIRONMENTAL}

81. 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 → 81a. Number of years | | | 81b. Where?

 No

_{ Don’t know}

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82. 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 → 82a. Number of years | | | 82b. Where?

 No

 Don’t know

83. 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 → 83a. Number of years | | | 83b. Where?}

_{83c. Chemicals used or manufactured there}

 No

 Don’t know

84. 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 → 84a. Number of years | | | 84b. Where?

 No

 Don’t know

85. 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 → 85a. Number of years | | | 85b. Where?

 No

 Don’t know

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

 Yes

 No

 Don’t know

86a. If yes

_{Name of Mine or Mill Number of Years worked there}

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

 Yes

 No

 Don’t know

_{87a. If yes}

_{Number or years Your age at the time}

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

88a. Playing on a uranium tailings pile or waste dump?

 Yes  No

88b. Playing outdoors near or next to a uranium mine, mill or waste dump?

 Yes  No

88c. Drinking, wading into or coming into contact with uranium mine water or waste spills?

 Yes  No

88d. Herding livestock on or next to a uranium mine, mill or waste dump?

 Yes  No

88e.Sheltering livestock in an abandoned mine?

 Yes  No

88f. Living in a mining camp?

 Yes  No

88g.Washing or handling clothes of a friend or family member who was a uranium worker?

 Yes  No

88h. Live in the same home with a uranium miner or miller?

 Yes  No

89. 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 → 89a. Number of years | | | 89b. Where?

 No

 Don’t know

90. 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 → 90a. Number of years | | | 90b. Where?

 No

 Don’t know

_{THANK YOU FOR YOUR TIME AND ATTENTION}