MI screener

Attachment 4a

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

Biomonitoring of Persistent Toxic Substances

in Michigan Urban Fisheaters

Screening Questionnaire

NOTE TO REVIEWERS

Readability has been calculated using the Fry Readability Formula for determining grade level at the 6^th grade level when sentences containing agency names are omitted

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Form Approved

OMB No. 0923-XXXX

Exp. Date/xx/xx/20xx

Interviewer Name:	Venue Name:____________	Date:
	Venue Number:__________	Time: _________ am / pm
Colleague Name:	Office Use Only
	Staff Entry Number:	Survey Number:
	Date of Entry:	Date Proofed:

Note to interviewer: The text in italics and unbold font is instructional or supporting information. Do not read aloud. CIRCLE or WRITE in answers.

SCRIPT Hello. My name is (first name). I am a student with Wayne State University. We are working on a fish eaters study with the Michigan Department of Community. Some fish from this area contain chemicals that can be found in the people who eat them. We are looking at the amount of these chemicals in people who eat the fish.

Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, 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 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 Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

1. Are you willing to answer a few questions?

[ ] Yes

[ ] No

If NO Okay thank you. GO to the next angler

If YES, Okay, let’s start with questions about eating fish. Here is a map of {Saginaw AOC/Detroit AOC}. SHOW map

2. Do you eat fish caught from the {Saginaw AOC/Detroit AOC}?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

3. How do you get the fish you eat from the {Saginaw AOC/Detroit AOC}?

[ ] You catch it

[ ] Someone else catches it

4. How many years have you been eating fish from the {Saginaw AOC/Detroit AOC}? If no number is given, suggest a range of years.

[ ] Less than 5 years

[ ] 5-10 years

[ ] more than 10 years

5. How many meals of fish from the {Saginaw AOC/Detroit AOC} would you say you’ve eaten in the last 30 days?

________ meals

6. What is the typical number of fish meals you eat per month from the {Saginaw AOC/Detroit AOC}?

________ meals

7. What kind of fish do you eat most often from the {Saginaw AOC/Detroit AOC}? LIST species. If only one species named, prompt for others.

_______________________ _______________________

_______________________ _______________________

_______________________ _______________________

_______________________ _______________________

_______________________ _______________________

8. Are you aware some fish have harmful chemicals in them?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

9. What is your age?

__________ years

10. Indicate whether the person is a male or female. If unsure, ask his/her gender.

M F

11. Do you consider yourself to be Hispanic or Latino?
    
    

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

12. What race or races do you consider yourself? CHECK all that apply.

[ ] White
[ ] Black or African American
[ ] Asian
[ ] Native Hawaiian or Other Pacific Islander
[ ] American Indian or Alaska Native
[ ] DK
[ ] Refused

If candidate is less than 18 years of age or eats less than two fish meals per month, he/she is ineligible for the study.

Ineligible script: I’m sorry but you are not eligible for this study. You must be at least 18 years of age and must eat at least two meals of fish per month. Here is a brochure with information about the fish advisory and a small gift [flashlight] for taking the time to talk with me today. Thanks so much! OFFER Eat Safe Fish brochure and flashlight.

CONTINUE If candidate is 18 years of age or older and eats more than two fish meals per month.

Script: It sounds like you eat fish pretty often from the {Saginaw AOC/Detroit AOC}. I’d like to find out if you would be interested in participating in the study. Let me explain.

The Michigan Department of Community Health will be asking 200 people from this area to be in the study. If you are asked, you can decide whether or not you want to be in the study. If you agree, we will schedule an appointment for you at a local clinic. During your appointment, we will ask you some additional questions. We will ask you to give a blood and urine sample. This appointment could take up to 2 hours. As a thank you, you will receive gift cards up to $75.

There is no cost to you to be in the study. You will also get your test results, if you want them. We can provide transportation if you need it.

13. Are you interested in being part of this study?

[ ] Yes

[ ] No

[ ] DK

If NO Okay. Here is a brochure with information about the fish advisory. Also, here’s a small gift [flashlight] for taking the time to talk with me today. Thanks so much! OFFER Eat Safe Fish brochure and flashlight.

14. IF DON’T KNOW Would you like someone to call you with more information about the study?

[ ] Yes

[ ] No

15. May I please have your name?
    
    First: ______________________________

Middle initial:_______________________

Last:_______________________________

16. Do you have a phone number where we can reach you? This can even be the phone number of a friend, relative, or someone who will know how to find you.

[ ] Yes

[ ] No (If checked, SKIP to Q 15)

[ ] DK

[ ] Refused

(if YES) What is/are the numbers where we can reach you?

Phone 1:__________________________  Home  Work  Cell

Phone 2: ___________________________ Home  Work  Cell

Phone 3:___________________________ Home  Work  Cell

Phone 4:___________________________ Relative/friend’s name: _______________

17. Which is the best number to reach you?
    
    

[ ] Phone 1

[ ] Phone 2

[ ] Phone 3

[ ] Phone 4

18. What is the best time of day to call you?

Time: __________________________________________AM/PM

19. What is your mailing address?

Street Number: _ _____ Street Name:__ _________________

Unit: _ _________ or P.O. Box: _________________________

City: ______________________State: _______ ZIP Code: ______________

Script: If you are selected to be in the study, someone from the Michigan Department of Community Health will call you. Here is a brochure that explains more about this project. There are phone numbers here [show page] that you can call if you have questions. Also, here’s a small gift [flashlight] for taking the time to talk with me today. Thank you!

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