Enrollment Survey for Fathers

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

Attach 3b Father Enroll 2-6-13

Enrollment Survey - father

OMB: 0923-0046

Document [docx]
Download: docx | pdf
Shape1

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx





Shape2 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

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

Shape3

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)

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 ($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)

Dont Know

Refused




HEALTH HISTORY


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

Yes

No

Dont know

Refused


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

Yes

No

Dont know

Refused


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

Yes

No

Dont know

Refused







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Shape4 Participant Number: Version 1_


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

Yes

No

Dont 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

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

Shape5 Child #1. Boy Girl / /


Shape6 Child #2. Boy Girl / /


Shape7 Child #3. Boy Girl / /


Shape8 Child #4. Boy Girl / /


Shape9 Child #5. Boy Girl / /


Shape10 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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Shape11 Participant Number: Version 1_


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.





5

Shape12 Participant Number: Version 1_


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 doctors prescription for?

Yes 22a. How many times?

Once or twice

10 or more times

Dont 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]



6

Shape13 Participant Number: Version 1_



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?


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

YEARS


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


| | _|

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


32. 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


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

Yes If Yes: 33a. Did you quit because of your partners pregnancy?

Yes

No

No


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


| | |

| | |

Dont Know

months quit

years quit



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

Yes

No

Dont 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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Shape14 Participant Number: Version 1_


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

Dont know

Refused


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

Once or more per week

Once per month

On occasion

Never






8

Shape15 Participant Number: Version 1_


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?

Shape16 [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

Dont 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

Dont know

Refused


48. How long have you lived in this home?

| | | Weeks

NUMBER ..... Months

.......... Years

.......... Dont 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

Dont know

Refused






9

Shape17 Participant Number: Version 1_


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:

Dont 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:

Dont 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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Shape18 Participant Number: Version 1_


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

Dont 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

Dont know

Refused


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

Yes

No

Dont 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

Dont know

Refused






11

Shape19 Participant Number: Version 1_


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

Dont know

Refused


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

Yes

No

Dont 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

Dont 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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Shape20 Participant Number: Version 1_


WATER USAGE


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

Yes No Dont 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 Dont 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

Dont 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

Dont know


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

Plastic

Metal

Glass

Wood

Concrete

Other Specify

Dont 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, dont do anything to the water

Dont know



13

Shape21 Participant Number: Version 1_


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

Dont 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

Dont know

Refused











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Shape30 Participant Number: Version 1_


FOOD BEHAVIORS


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


Shape31 69a. Where do the livestock graze? (Using map, locate grazing area)



Shape32 Shape33 Shape34 Shape35 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 Dont know


72. Do you use the water you haul for the vegetables you grow? Yes No Dont 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:

Dont know

Refused







15

Shape36 Participant Number: Version 1_



Shape37 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

Dont know

Refused

76a. If yes, complete the following

Shape38 Substance Brand/Name Used Indoor Used outdoors How Long


Shape39 Shape40 Shape41 Pesticide


Shape42 Shape43 Chemicals


Shape44 Other


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

Shape45 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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Shape46 Participant Number: Version 1_



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

Dont know


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

Yes

No

Dont 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

Dont know





17

Shape47 Participant Number: Version 1_


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

Dont 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?


Shape48 83c. Chemicals used or manufactured there


No

Dont 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

Dont 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

Dont know


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

Yes

No

Dont know

86a. If yes

Shape49 Shape50 Shape51 Shape52 Shape53 Shape54 Shape55 Shape56 Name of Mine or Mill Number of Years worked there






















18


Shape57 Participant Number: Version 1_


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

Yes

No

Shape58 Shape59 Dont know

87a. If yes

Shape60 Shape61 Shape62 Shape63 Shape64 Shape65 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

Dont 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

Dont know




THANK YOU FOR YOUR TIME AND ATTENTION


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