3 BEEA Dust Specimen Questionnaire

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_______________– DT02

HE STUDY OF BIOMARKERS OF EXPOSURES

AND EFFECTS IN AGRICULTURE

Dust Collection Questionnaire

If you own a vacuum cleaner, and if you agree, we would like to collect the dust from your machine. Between now and your visit, you may use your vacuum cleaner as you normally would, but we ask that you not empty it or change bags if possible. If you do need to change bags or empty the vacuum canister, we ask that you try to use the vacuum at least once with the new bag or empty canister before your visit, so there is dust available in the machine. When we come to your home, we will ask to see the machine and will either remove the used bag or empty the dust from the machine or bag. If you have more than one vacuum machine, we would like to obtain the dust sample from the vacuum you use most frequently in your home. If the machine you use most often is a hand-held vacuum or shop vac, and you also own a standard vacuum cleaner, we would like to obtain the dust sample from the standard vacuum.

We have prepared this brief questionnaire to ask for information about your vacuum cleaner, recent use, and the areas in your home where you may have vacuumed. If there are others in your household that can help you with answering these questions, please feel free to share the questionnaire with them. We will collect and review your questionnaire during the home visit. Please call us at 1-800-xxx-xxxx if you have any questions.

Instructions

• Please use a black or blue pen to complete this form. Do not use a felt-tip pen or a pencil.

• Mark  to indicate your answer.

• If you want to change your answer, mark through the box on the wrong answer , and mark the correct answer.

• Your answers are important. Please print clearly using uppercase, block letters (for example, “WEDNESDAY”).

Today’s Date: |___|___| / |___|___| / |___|___|

M M D D Y Y

1. Type of vacuum:  Standard vacuum (with a disposable bag) Bagless vacuum Handheld vacuum (with a disposable bag) Handheld vacuum (without a bag or with a reusable cloth bag) Central house collection system Robotic vacuum Hard surface vacuum (with a disposable bag) Hard surface (without a bag or with a reusable cloth bag) Shop vac Other, specify____________________

2. Make and model of vacuum: For example: Make: Hoover Model#: Windtunnel Rewind H09A Make: _______________________________ Model#: _____________________________

Public reporting for this collection of information is estimated to average ten minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406). Do not return the completed form to this address.

3. Approximately, how long has it been since the vacuum was last used? Enter the number and select the time period from the choices below. |___|___|  Days  Months  Refused  Weeks  Years  Don’t know 4. Have you changed your vacuum bag or emptied the dust from your vacuum since it was last used?  Yes  No 5. Approximately, how long has it been since you changed your vacuum bag or emptied the dust from your vacuum cleaner? Enter the number and select the time period from the choices below. |___|___|  Days  Months  Refused  Weeks  Years  Don’t know 6. Since the vacuum bag was changed or since you emptied the dust from your vacuum, has your vacuum been used in a place other than inside your home, such as. . .? MARK ALL THAT APPLY  Your car  Your garage  Your porch  Someone else’s home  Central house collection system  A hallway outside your apartment  Other, specify____________________  Not applicable, vacuum only used in home 7. Approximately, how many rooms are usually vacuumed with this vacuum cleaner? |___|___| 8. Approximately, how many rooms that are vacuumed have carpets or rugs? |___|___|

9. Approximately when did you most recently replace any carpets or rugs in the room(s) where you use this vacuum?  Less than 6 months ago  Between 6 months and 1 year ago  Between 1 and 5 years ago  More than 5 years ago 10. Approximately when was this home built?  Before 1940  Between 1940 and 1969  Between 1970 and 1989  Between 1990 and 2009  After 2009 11. Do you have air conditioning in your home?  Yes  No If yes, do you have central air or another system, such as a window unit?  Central Air  Other system, such as a window unit 12. Would you say that you and other members of your household remove your shoes before entering the house. . .?  Always or almost always  Sometimes  Almost never or never 13. Would you say that you and other members of your household remove your work shoes or boots before entering the house. . .?  Always or almost always  Sometimes  Almost never or never

Thank you very much for completing this questionnaire. All of your answers are very important.

For safekeeping, please store your completed questionnaire with the other documentation from your pre-visit package until the day of home visit.

v. 03/7/13