Form 0923-0044 Att3_MI_BiomQs_20120619

Biomonitoring of Great Lakes Populations Program

Att3_MI_BiomQs_20120619

Michigan Biomonitoring of Great Lakes Populations

OMB: 0923-0044

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Attachment 3

(originally numbered Attachment 4e, no changes requested)


MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF ENVIRONMENTAL HEALTH


Biomonitoring of Persistent Toxic Substances

in Michigan Urban Fisheaters



Biomonitoring Questionnaire

















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






OMB: Attachment 4e. Biomonitoring Questionnaire

OMB page 2: Consider only asking for this on the consent form

Contact Information

ATSDR/MDH response: The biomonitoring questionnaire no longer collects address and personal information. This has been moved to the consent process. A Contact Information Form (Attachment 4b) has been created which will be filled in with information collected at the onshore recruiting. Respondents will be asked to verify contact information collected at the onshore recruiting instead of open ended questions to gather this information again.



OMB page 23: Animal

/AMINAL] at

ATSDR/MDH response: the spelling had been corrected.



OMB page 29: What’s the intended use of this data?



Now I’d like to measure your blood pressure.



Measurement: ___ / ___



[ ] Refused

ATSDR/MDCH response:

Blood pressure will be assessed prior to blood sample collection to ensure that participants may safely give the required volume of blood. The Certified Phlebotomy Technician or other qualified person will assess the participants’ blood pressure prior to collection of a blood sample. Blood samples will be collected from participants whose blood pressure is below 180/100 (systolic/diastolic) and above 80/50 (systolic/diastolic). Participants will be given am American Heart Association blood pressure information (Attachment 10a7) sheet to take with them. Blood pressure readings will be verbally shared with participants and recorded, but will not be retained for any analytical purpose.























This page intentionally left blank





















Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx


SURVEY QUESTIONNAIRE






Date of Interview:___________________________


Interviewer Name:__________________________




Introductory Script: Hello. My name is _________________. Thank you for agreeing to be part of this study. I am going to ask you some questions about you and your normal activities…things like your age, where you live, foods you eat, and a few questions about your lifestyle. Everyone in the study will be asked the same questions.


It will take about one hour to go through all of the questions.


Before we start, I want to remind you about a few things:


First, tell me if I’m going too fast or if you would like to take a break. Also, you don’t have to answer any questions that you don’t want to. Just tell me that you “don’t want to answer” and we’ll skip the question.


Second, if you are not sure about an answer, do the best you can. If you can’t remember or don’t know, just tell me “I don’t know”.


Third, please do the best you can, because your answers are very important. They will help us learn how people have come into contact with chemicals in the environment.


Finally, you can tell me to stop if you don’t want to finish answering these questions.


Do you have any questions for me?


Okay, let’s get started.



Public reporting burden of this collection of information is estimated to average 52 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).




Note to interviewer: The text in italics are instructions or supporting information. Do not read aloud.




Contact Information

Script: We need some information about how to reach you so we can send you the results of the tests done on your blood and urine. All the information you give in this first part will be stored separately from the rest of the things you tell me.


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

M F



  1. What is your birthdate?


dd / mm / yyyy


[ ] DK

[ ] Refused

10a. Confirm: So that would make you [XX] years old.


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

[ ] Yes

[ ] No

[ ] DK

[ ] Refused


  1. 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




RESIDENTIAL HISTORY

Script: Next, I will ask a few questions about where you have lived.

  1. How long have you lived at your current address?

_____ years _____ months


If ENTIRE LIFE, enter age in years

If less than 1 year, enter 00 years and number of months reported.

If full years reported, enter number of years and 00 months.


  1. How long have you lived in {Saginaw AOC/Detroit AOC}? SHOW MAP

_____ years _____ months

If ENTIRE LIFE, enter age in years

If less than 1 year, enter 00 years and number of months reported.

If full years reported, enter number of years and 00 months.



current home


Script: I'd like to ask you a few questions about where you live now.


  1. When was this home built?

[ ] 1978 or newer

[ ] Between 1960 and 1977

[ ] Before 1960

[ ] DK

[ ] Refused



  1. Have you ever been told that your current home has lead paint?

[ ] Yes

[ ] No (If checked, SKIP to Q 18)

[ ] DK

[ ] Refused










  1. (if YES) Was the lead paint removed from your home?

[ ] Yes, by the residents

[ ] Yes, by a professional

[ ] No

[ ] DK

[ ] Refused



  1. In the past 7 days, were any chemical fertilizers used in your lawn or garden?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused


  1. Does the water used for drinking and cooking in your home come from a public water supply, a private well, or something else? (May choose more than one)

[ ] Public Water Supply

[ ] Private Well

[ ] Something Else
[ ] DK

[ ] Refused



  1. Have you ever had your drinking water tested for lead or arsenic?

[ ] Yes

[ ] No (If checked, SKIP to Q 22)

[ ] DK

[ ] Refused




  1. (if YES) Did the test show that you had lead or arsenic in your water?

[ ] Yes, lead

[ ] Yes, arsenic

[ ] Yes, lead and arsenic

[ ] No

[ ] DK

[ ] Refused







EDUCATION & OCCUPATION


  1. What is the highest grade, level of school, or degree you have completed? SHOW CARD, if necessary.

[ ] 8th grade or less
[ ] 9
th to 12th grade, no diploma
[ ] High school graduate or GED
[ ] Some college, no diploma
[ ] Associate Degree
[ ] Bachelors Degree
[ ] Postgraduate, Professional, or Doctoral Degree


Script: I want to know what type of work you’ve done and the kind of business where you worked in the last 12 months.



  1. What best describes your job status in the past 12 months? (If status changed within the past 12 months, enter current category)

[ ] Employed and not a student
[ ] Employed and a s
tudent
[ ]
A student and not employed

[ ] Looking for work

[ ] Homemaker

[ ] Retired

[ ] Unable to Work
[ ] Refused


  1. Currently, what is your job or job title and the kind of business or organization where you work?

Job 1 _____________________________________ Industry 1 _______________________________________


  1. What are your usual activities or duties?

__________________________________________________________________________________________



  1. If you had more than one job in the past 12 months, tell me about each.

Job 2 _____________________________________ Industry 2 _______________________________________


What {are/were} your usual activities or duties?
________________________________________________________________________________



Job 3 _____________________________________ Industry 3 _______________________________________


What {are/were} your usual activities or duties?

________________________________________________________________________________



Job 4 _____________________________________ Industry 4 _______________________________________


What {are/were} your usual activities or duties?

________________________________________________________________________________




Script: Now I will ask you about jobs you have held where you have come into contact with chemicals. Be sure to include seasonal work, self-employment, military service, and farm work in your answers.


WORK HISTORY


As part of a job, have you ever… CHECK response



(if YES) What {is/was} your job title/description?

(if YES)

Year started job

(if YES)

Year ended job

  1. Have you ever applied pesticides that kill insects, fungus, or weeds?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

27a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

27b

________year

27c

________year

  1. Have you ever worked for a trash or recycling company?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

28a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

28b

________year

28c

________year

  1. Have you ever worked in a foundry, a smelter, a welding facility or steel mill?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

29a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

29b

________year

29c

________year

  1. Have you ever removed lead paint?


[ ] Yes

[ ] No

[ ] DK

[ ] Refused

30a Job title/description

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

__________________________________________________

30b

________year

30c

________year

  1. Have you ever worked with commercial electrical equipment such as transformers, or capacitors or worked for an electric power company?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

31a Job title/description


__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

31b

________year

31c

________year

  1. Have you ever been a maintenance worker in any type of heavy industry?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

32a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

32b

________year

32c

________year

  1. Have you ever worked for a battery manufacturing or recycling company?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

33a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

33b

________year

33c

________year

  1. Have you ever worked for a chemical manufacturing company?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

34a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

34b

________year

34c

________year

  1. Have you ever worked for an automobile manufacturing company?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

35a Job title/description

__________________________________________________

­­­­­­­­­­­­­­­­__________________________________________________

__________________________________________________

35b

________year

35c

________year


LIFESTYLE


Script: We also want to know about a few lifestyle choices that might increase or decrease the amount of chemicals in your body.



  1. Most days, do you take any dietary supplements that have fish oil or other Omega 3 oil?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



  1. Most days, do you take any store-bought herbal supplements?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused


  1. Have you smoked at least 100 cigarettes (5 packs) in your lifetime?

[ ] Yes

[ ] No (if checked, SKIP to Q 44)

[ ] DK

[ ] Refused



  1. (If YES) Do you smoke cigarettes now?

[ ] Yes (if checked, SKIP to Q 42)

[ ] No

[ ] DK

[ ] Refused


  1. (If NO) How long has it been since you last smoked cigarettes regularly? CIRCLE months or years

_____ months/years



  1. (if NO) For how many {months/years} did you smoke? CIRCLE months or years

_____ months/years







  1. (If YES, CURRENT SMOKER) How often do you smoke cigarettes?

[ ] Daily

[ ] Weekly (if checked, SKIP to Q 43)

[ ] Monthly (if checked, SKIP to Q 43)

[ ] DK

[ ] Refused



  1. (If DAILY) How many cigarettes do you smoke per day?

Note: One pack equals 20 cigarettes

[ ] 1-5 per day

[ ] 6-10 per day

[ ] 11-20 per day

[ ] > 20 per day

[ ] DK

[ ] Refused


  1. For how many {months/years} have you smoked? CIRCLE months or years

    _____ months/years


  1. Does anyone smoke cigarettes inside your home?

[ ] Yes

[ ] No (if checked, SKIP to Q 46)

[ ] DK

[ ] Refused


  1. (If YES) How often do household members or guests smoke cigarettes in your home?

[ ] Daily
[ ] Weekly
[ ] Monthly
[ ] DK
[ ] Refused















BIRTHS

(If MALE, SKIP to Q 49)

(If FEMALE, READ Script) We want to know if you ever had children, because giving birth and nursing can change the amount of some chemicals in the body.


  1. How many children have you given birth to? (if none, ENTER “0” and SKIP to Q 49)

______ child/children




Birth Order (Oldest-to-Youngest)

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

  1. From oldest to youngest, what year was each child born?











  1. How many months {were your children/was your child} breastfed?

















Script: The next questions are about activities or interests done as hobbies. You may do these activities for fun, to earn money, or to keep up your house.




HOBBIES AND ACTIVITIES



  1. In the past 12 months, have you done any of the following activities at home or somewhere else?

  1. In the past 12 months, has someone else living in your household done any of these activities in your home?

Dyeing material
(Ex: textiles, making quills)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Electronics assembly
(Ex: computer circuits, radios, robot kits)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Gardening or farming

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Glass crafting
(Ex: stained glass, glassblowing)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Leathercrafting
(Ex: leather crafts, taxidermy, tanning hides - chemical or brain)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Metal working
(Ex: enameling, jewelry making, making fishing sinkers, loading shotgun shells, casting bullets, lost wax casting)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Painting and glazing
(Ex: household painting, art, ceramics making)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Printmaking
(Ex: intaglio, etching, lithography)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

Woodworking
(Ex: cabinet making, carpentry, furniture making, wood turning, working with treated lumber)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

[ ] Yes

[ ] No

[ ] DK

[ ] Refused





  1. In the past 12 months, about how many times did you swim, dive or wade in Saginaw area rivers or lakes or the Detroit River? (if none, enter “00”)

__ times



Script: Food has many health benefits, but it can also contain chemicals from the environment. In this part of the interview, I will ask you questions about fish, wild animals, home-raised, and home-grown foods that you eat.


For most of these questions, I will ask how many times you ate each food in the past 12 months. You can answer in number of times per week, per month, or in the past year. Answer each question as best you can.


FISH CONSUMPTION


Script: These questions are about the caught fish that you eat from Michigan waters. By caught fish I mean fish caught by you, a family member, or an acquaintance; not fish you bought from a store or ate in a restaurant. By Michigan waters, I mean any river or lake in Michigan, including the Great Lakes.



  1. Have you eaten fish or shellfish in past week?

[ ] Yes

[ ] No (if checked, SKIP to Q 55)

[ ] DK

[ ] Refused


  1. (If YES to Q 53) When was the last time you ate fish or shellfish?

[ ] Today/same day

[ ] Yesterday/1 day ago

[ ] Day before yesterday/2 days ago

[ ] 3 days ago

[ ] 4-7 days ago

[ ] DK

[ ] Refused



  1. (SHOW MODEL) Compared to the {picture/mode}] of a half-pound serving of fish, would you say that a meal of fish you eat is usually

[ ] Smaller than the model
[ ] Same or about the same size as the model
[ ] More than the model
[ ] DK
[ ] Refused


  1. Over your lifetime, how many years have you eaten fish of any type caught from Michigan waters? (If NEVER or LESS THAN 1 YEAR, ENTER 00)

_______ years


  1. Over your lifetime, how many years have you eaten fish from the Saginaw AOC? (If NEVER or LESS THAN 1 YEAR,ENTER 00)

    _______ years


  1. Over your lifetime, how many years have you eaten fish from the Detroit AOC? (If NEVER or LESS THAN 1 YEAR,ENTER 00)

_______ years


  1. Over your lifetime, how many years have you eaten fish from the Great Lakes? (If NEVER or LESS THAN 1 YEAR,ENTER 00)

_______ years


SCRIPT: The next questions are about caught fish from Michigan waters that you have eaten at leave five times in your lifetime. (SHOW CAUGHT FISH CARD)


  1. Have you eaten [SPECIES] at least five times in your life? (If YES, COMPLETE Caught Fish Eaten table. Use separate Table for each [SPECIES] consumed)

Bluegill (SunfIsh) [ ] Y [ ] N [ ] DK

Brook trout [ ] Y [ ] N [ ] DK

Brown trout [ ] Y [ ] N [ ] DK

Bullhead [ ] Y [ ] N [ ] DK

Carp [ ] Y [ ] N [ ] DK

Catfish [ ] Y [ ] N [ ] DK

Crappie (White, Black, Calico, Strawberry Bass) [ ] Y [ ] N [ ] DK

Eelpout (Burbot, Ling. Lawyer, Freshwater cod) [ ] Y [ ] N [ ] DK

Freshwater drum (Sheepshead) [ ] Y [ ] N [ ] DK

Lake herring (Cisco, Tullibee) [ ] Y [ ] N [ ] DK

Lake trout [ ] Y [ ] N [ ] DK

Largemouth bass (Black bass) [ ] Y [ ] N [ ] DK

Muskellunge (Muskie) [ ] Y [ ] N [ ] DK

Northern pike [ ] Y [ ] N [ ] DK

Rainbow smelt [ ] Y [ ] N [ ] DK

Rainbow trout (Steelhead) [ ] Y [ ] N [ ] DK

Rock bass [ ] Y [ ] N [ ] DK

Salmon [ ] Y [ ] N [ ] DK
Sucker
[ ] Y [ ] N [ ] DK

Smallmouth bass (Black bass) [ ] Y [ ] N [ ] DK

Walleye [ ] Y [ ] N [ ] DK

Whitefish [ ] Y [ ] N [ ] DK

White bass (Silver bass) [ ] Y [ ] N [ ] DK

White perch [ ] Y [ ] N [ ] DK

Yellow perch [ ] Y [ ] N [ ] DK

Other, specify _____________________________

Other, specify _____________________________

Other, specify _____________________________

[ ] DK

[ ] Refused


CAUGHT FISH EATEN


USE separate Table for each [SPECIES] consumed)


  1. (if YES) In your lifetime, have you eaten [SPECIES] that were caught from {Saginaw AOC/Detroit AOC}?

  1. (if YES) How many years have you eaten [SPECIES] from {Saginaw AOC/Detroit AOC}? (If NEVER, ENTER 00 years)

  1. In the past 12 months, did you eat [SPECIES] from {Saginaw AOC, Detroit AOC, or Other Location}? WRITE name of up to three lakes or rivers and counties for Other Location.

  1. (If YES) In the past 12 months, how many times did you eat [SPECIES] from {Saginaw AOC/Detroit AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)


_________________

(Write SPECIES name)



[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused


________ years





[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



___times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused


[ ] Yes, Detroit AOC

[ ] No

[ ] DK

[ ] Refused



________ years


[ ] Yes, Detroit AOC

[ ] No
[ ] DK

[ ] Refused



_ times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of up to three lakes or rivers and counties where fish were caught most often: ______________________________________________

_______________________

[ ] No

[ ] DK

[ ] Refused



_ times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused




Script: Now I’d like to ask you how the fish, caught by you or someone you know, was prepared and cooked for your meals.


  1. What parts of the fish did you usually eat in the past 12 months? (CHECK all that apply)

[ ] Fillet

[ ] Skin

[ ] Cheeks
[ ] Eggs/Roe
[ ] Liver

[ ] Other, specify _____________________


  1. How was the fish that you ate in the past 12 months usually cleaned? (CHECK all that apply)

    [ ] Trimmed fat
    [ ] Trimmed belly meat
    [ ] Removed/punctured skin
    [ ] Removed guts/gutted
    [ ] Other, specify ______________________


  2. How was the fish that you ate in the past 12 months usually cooked? (CHECK all that apply)

    [ ] Pan fry
    [ ] Deep fried
    [ ] Baked/Broiled
    [ ] Boiled/Poached
    [ ] Smoked
    [ ] Stewed/Chowder
    [ ] Dried
    [ ] Grilled
    [ ] Eaten raw
    [ ] Pickled
    [ ] Other, specify _____________________


  1. For fish caught in any of these areas (SHOW MAPS), how has the total amount of fish you eat changed during the past five years?

Saginaw AOC Detroit AOC Other locations


[ ] Eat less [ ] Eat less [ ] Eat less
[ ] Eat about the same [ ] Eat about the same [ ] Eat about the same
[ ] Eat more [ ] Eat more [ ] Eat more
[ ] N/A [ ] N/A [ ] N/A




STORE / MARKET / RESTAURANT FISH

Script: The following questions are about fish you have eaten that were bought at a store, supermarket, or restaurant. (SHOW State Bought List)


FISH BOUGHT FROM A STORE, SUPERMARKET, OR RESTAURANT


SPECIES

  1. Which fish have you eaten at least five times in your life from a store, supermarket, or restaurant? SHOW CARD

  1. (If [SPECIES] is YES) How many years did you eat [SPECIES] from a store, supermarket or restaurant? (If NEVER, enter 00 years)

  1. In the past 12 months, have you eaten [SPECIES] bought from a store, supermarket, or restaurant? Tell me the number of times per week, month, or year, whichever is easiest to remember. [If NEVER, enter 00 times per year)

Catfish

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Salmon

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Trout

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Tuna (canned)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Tuna (steak/filet, not canned)

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years

_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Whitefish

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Group A: Cod, Haddock, Herring, Freshwater Perch, Ocean Perch, Pollock, Scallops, Shrimp, Tilapia

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Group B: Ocean Bass, Grouper, Halibut, Mackerel, Mahi Mahi, Orange Roughy, Snapper

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years

_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused


Group C: King Mackerel, Shark, Swordfish, Tilefish

[ ] Yes

[ ] No

[ ] DK

[ ] Refused



_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused



Other: SPECIFY

___________________


[ ] Yes

[ ] No

[ ] DK
[ ] Refused

_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused




Other: SPECIFY

___________________



[ ] Yes

[ ] No

[ ] DK

[ ] Refused

_____ years

_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused




Other: SPECIFY

___________________



[ ] Yes

[ ] No

[ ] DK

[ ] Refused

_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused




Other: SPECIFY

___________________



[ ] Yes

[ ] No

[ ] DK

[ ] Refused

_____ years


_ times per [ ] wk

[ ] mo

[ ] year

[ ] DK

[ ] Refused




wild birds AND animals


Script: The next questions are about hunted wild birds or animals that you have eaten at least five times in your lifetime.


  1. Have you eaten [SPECIES] at least five times in your life? (If YES, COMPLETE Wild Bird/Animal Eaten Table. Use separate table for each [SPECIES] consumed)

Deer (Venison) [ ] Y [ ] N [ ] DK

Duck, Goose, Coot [ ] Y [ ] N [ ] DK

Grouse, pheasant, turkey, or other upland bird [ ] Y [ ] N [ ] DK

Raccoon, rabbit, squirrel, porcupine, other small animal [ ] Y [ ] N [ ] DK

Turtle [ ] Y [ ] N [ ] DK

WILD BIRD/ANIMAL EATEN

  1. (If YES) Have you eaten [WILD BIRD/ANIMAL] at least five times in your lifetime that was/were hunted from {Saginaw AOC/Detroit AOC}? SHOW CARD.

  1. (If YES) How many years have you eaten [WILD BIRDS/ANIMALS] from {Saginaw AOC/Detroit AOC}? (If NEVER, ENTER 00 years)

  1. In the past 12 months, did you eat [WILD BIRD/AMINAL] that were hunted from {Saginaw AOC/Detroit AOC/Other Location}? (WRITE name of county for Other Location)

  1. (If YES) In the past 12 months, how many times did you eat [WILD BIRD/ANIMAL] from {Saginaw AOC/Detroit AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)



________________

(Write SPECIES name)


[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



________ years


[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



_ times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused

[ ] Yes, Detroit AOC

[ ] No
[ ] DK

[ ] Refused



________ years


[ ] Yes, Detroit AOC

[ ] No
[ ] DK

[ ] Refused



_ times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused


[ ] Yes, Other Location

Name of counties: ______________________________________________

_______________________

[ ] No

[ ] DK

[ ] Refused



_ times per [ ] wk

[ ] mo

[ ] year
[ ] DK

[ ] Refused





  1. In the past 12 months, what parts of the [Wild Bird or Animal] did you usually eat? (CHECK all that apply. If NONE, enter 00)

[ ] Meat

[ ] Skin

[ ] Liver

[ ] Other, specify ___________________________________________________

[ ] DK

[ ] Refused




home-raised or home-grown FOODS


Script: The next set of questions is about home-raised birds or animals and home-grown vegetables and fruit. For this interview, “home-raised” and “home-grown” means not purchased in a grocery store or market and not wild.

























HOME- RAISED, HOME- GROWN FOOD EATEN


FOOD

  1. Which of these [HOME- RAISED, HOME- GROWN FOOD] have you ever eaten at least five times in your lifetime?

  1. (If YES) Was/were the [HOME- RAISED, HOME-GROWN FOOD] you ate raised in {Saginaw/Other Location}? (SHOW MAPS. MARK all that apply)

  1. How many years have you eaten [HOME- RAISED, HOME-GROWN FOOD] from {Saginaw AOC/Other Location}? (If NEVER, ENTER 00 times per year)

  1. In the past 12 months, how many meals of [HOME-RAISED, HOME-GROWN FOOD] did you eat from {Saginaw AOC/Other Location}? Tell me the number of times per week, month, or year, whichever is easiest to remember. (If NEVER, ENTER 00 times per year)

Eggs









[ ] Yes

[ ] No

[ ] DK [ ] Refused



[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



________ years




_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of counties: ____________________________________________________

[ ] No

[ ] DK

[ ] Refused



________ years



_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused


Milk and other dairy products








[ ] Yes

[ ] No

[ ] DK [ ] Refused




[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



________ years



_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of counties: ____________________________________________________

[ ] No

[ ] DK

[ ] Refused




________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused





Poultry or poultry products (chicken, duck, goose, turkey)










[ ] Yes

[ ] No

[ ] DK [ ] Refused



[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of counties: ____________________________________________________

[ ] No

[ ] DK

[ ] Refused



________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused









Meat and meat products (other than poultry)










[ ] Yes

[ ] No

[ ] DK [ ] Refused




[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused



________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of counties: ____________________________________________________

[ ] No

[ ] DK

[ ] Refused



________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused


Home-grown vegetables and fruit








[ ] Yes

[ ] No

[ ] DK [ ] Refused




[ ] Yes, Saginaw AOC

[ ] No
[ ] DK

[ ] Refused




________ years




_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused



[ ] Yes, Other Location

Name of counties: ____________________________________________________

[ ] No

[ ] DK

[ ] Refused



________ years


_ times per [ ] wk for

[ ] mo for

[ ] year
[ ] DK

[ ] Refused


  1. What parts of the home-raised poultry did you usually eat?

    [ ] Meat
    [ ] Skin
    [ ] Liver
    [ ] Other _______________________



  1. What parts of the home-raised animals did you usually eat?

    [ ] Meat
    [ ] Skin
    [ ] Liver
    [ ] Kidney
    [ ] Other _______________________



DEMOGRAPHICS


Script: To help us compare results between groups of people, it is useful to know the annual income of the study participants. This information can also be useful when planning public health policies and programs. This is the final set of questions.



Script: We consider your family to include everyone currently living with you, who is related by birth, marriage, or adoption and unmarried partners.

  1. Including yourself, how many family members currently live with you?

_________ number of family members


  1. Can you tell me your total family income in {LAST CALENDAR YEAR} before taxes? SHOW CARD

[ ] Less than $25,000

[ ] $25,000 to less than $35,000

[ ] $35,000 to less than $50,000

[ ] $50,000 to less than $75,000

[ ] $75,000 to less than $100,000

[ ] $100,000 or more

[ ] DK

[ ] Refused










Closing Script:


Thank you for answering these questions. I know it took awhile but the information you gave me is very important to this study.


We will send you a letter with your test results at the mailing address you gave me. Most everyone will receive their letters after we get the test results from all of the people in the study. However, we will let you know as soon as possible if any of your test results are high enough that we think you should be notified right away. In that case, there may be things you want to do to protect your health.


Do you have any questions about the study or how you will get your results? If have questions after you leave, you can contact us at the number in your copy of the Consent Form.


Will you need transportation when you are done? If so, stop by the reception desk and they will help you.


If you don’t have any questions, I will show you where to find the (nurse/phlebotomist). (She/he) will get your height, weight, and blood pressure. (She/he) will also ask you whether or not you have gained or lost weight in the last year. Then (she/he) will get your blood and urine samples.


Thank you for coming in today. You can pick up your gift card at the reception desk on your way out.




Clinical Measurements

Now we’ll measure your height.


Measurement: ______ft ______ in


[ ] Refused


Next I’d like to measure your weight.


Measurement: ______lbs


[ ] Refused



Hand Cards and Response Categories




EDUCATION LEVEL OR DEGREE

8th Grade or less

9th to 12th Grade, No Diploma
High School Graduate or GED
Some College, No Diploma
Associate Degree
Bachelor Degree
Postgraduate, Professional, or Doctoral Degree



TYPES OF INCOME

Earnings

Unemployment compensation

Workers’ compensation

Social security

Supplemental security income

Public assistance

Veterans’ payments

Survivor benefits

Disability benefits

Pension or retirement income

Interest

Dividends

Rents, royalties, and estates and trusts

Educational assistance

Alimony

Child support

Financial assistance from outside of the household

Other income








TOTAL FAMILY INCOME


Less than $25,000

$25,000 to less than $35,000

$35,000 to less than $50,000

$50,000 to less than $75,000

$75,000 to less than $100,000

$100,000 or more













Caught Fish

Bluegill (Sunfish)

Brook trout

Brown trout

Bullhead

Carp

Catfish

Chinook salmon (King salmon)

Coho salmon

Black/White crappie (Calico, Strawberry bass)

Eelpout (Burbot, Ling, Lawyer, Freshwater cod)

Freshwater drum (Sheepshead)

Lake herring (Cisco, Tullibee)

Lake trout

Largemouth bass (Black bass)

Muskellunge (Muskie)

Northern pike

Rainbow smelt

Rainbow trout (Steelhead)

Rock bass

Smallmouth bass (Black bass)

Sturgeon

Suckers

Walleye

Whitefish

White bass (Silver bass)

White perch

Yellow perch



Bought Fish


Catfish

Salmon

Trout

Tuna (canned)

Tuna (steak/fillet, not canned)

Whitefish

Group A – Cod, Haddock, Herring, Freshwater perch, Ocean perch, Pollock, Scallops, Shrimp, Tilapia

Group B – Ocean bass, Grouper, Halibut, Mackerel, Mahi Mahi, Orange Roughy, Snapper

Group C – King Mackerel, Shark, Swordfish, Tilefish








Wild Game


Deer

Duck, Goose, Coot

Grouse, pheasant, turkey or other upland bird

Raccoon, Rabbit, Squirrel, Porcupine, Other Small Animal

Turtle


File Typeapplication/msword
File TitleQuestionnaire Elements
AuthorStephanie Davis
Last Modified ByCDC User
File Modified2014-07-30
File Created2014-07-30

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