22.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Dust Wipe-Organics Instrument, Phase 2g

OMB Specification

Dust Wipe-Organics Instrument

Event Category:	Time-Based
Event:	36M, 48M, 60M
Administration:	N/A
Instrument Target:	Child's Primary Residence
Instrument Respondent:	Primary Caregiver
Domain:	Environmental
Document Category:	Sample Collection
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI
OMB Approved Modes:	In-Person, CAI
Estimated Administration Time:	1 minute
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

​*This instrument is OMB-approved for multi-mode administration, but this version of the instrument is designed for administration in this/these mode(s) only.

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Dust Wipe-Organics Instrument

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

WIPE-ORGANICS INSTRUMENT - DATA COLLECTOR QUESTIONS 3

WIPE-ORGANICS PRIMARY SAMPLE 5

WIPE-ORGANICS BLANK SAMPLE 8

WIPE-ORGANICS DUPLICATE SAMPLE 10

WIPE-ORGANICS SPIKE SAMPLE 12

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Dust Wipe-Organics Instrument

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

WIPE-ORGANICS INSTRUMENT - DATA COLLECTOR QUESTIONS

(TIME_STAMP_WOI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• PRELOAD DWELLING_UNIT_ID FOR THE DWELLING UNIT.

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR CAREGIVER.

• PRELOAD MULT_CHILD AND CHILD_NUM (IF MULT_CHILD = 1), FROM PVST INSTRUMENT.

• IF MULT_CHILD = 1, PRELOAD CHILD_QNUM.

WOI01000/(STAFF_ID). ENTER STAFF ID

__________________________________________

STAFF ID

WOI02000/(WIPE_ORG_SAMPLES). WHICH WIPE-ORGANICS SAMPLES ARE SCHEDULED FOR THIS VISIT?

Label	Code	Go To
WIPE-ORGANICS PRIMARY ONLY	1	WIPE_ORG_OKAY
WIPE-ORGANICS PRIMARY AND QC SAMPLE(S)	2

WOI03000/(WIPE_ORG_SUBSAMPLES). WHICH WIPE-ORGANICS QC SAMPLES ARE SCHEDULED FOR THIS VISIT?

DATA COLLECTOR INSTRUCTIONS

• SELECT ALL THAT APPLY.

Label	Code	Go To
WIPE-ORGANICS BLANK	1
WIPE-ORGANICS DUPLICATE	2
WIPE-ORGANICS SPIKE	3

WOI04000/(WIPE_ORG_OKAY). We would like to collect a wipe sample from your home.  Is that okay?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

WOI05000/(WIPE_ORG_REFUSE). RECORD REASON FOR REFUSAL IF GIVEN.

Label	Code	Go To
NONE GIVEN	1	WIPE_ORG_COMMENTS
NOT INTERESTED IN WIPE SAMPLE COLLECTION	2	WIPE_ORG_COMMENTS
OTHER	-5

WOI06000/(WIPE_ORG_REFUSE_OTH). SPECIFY: _________________________________

SOURCE

New

WOI07000/(WIPE_ORG_COMMENTS). RECORD ANY COMMENTS ABOUT THE WIPE-ORGANICS SAMPLE COLLECTION:

COMMENTS: _____________________________________________________

(TIME_STAMP_WOI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• IF WIPE_ORG_OKAY = 2, -1, OR -2, GO TO TIME_STAMP_WOS_ET.

• OTHERWISE, GO TO TIME_STAMP_WOP_ST.

WIPE-ORGANICS PRIMARY SAMPLE

(TIME_STAMP_WOP_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

WOP01000. COLLECTION INSTRUCTIONS

DATA COLLECTOR INSTRUCTIONS

• COLLECT THE WIPE-ORGANICS SAMPLE AT THE BORDER OF THE PARTICIPANT’S MOST USED ROOM FROM NON-CARPETED FLOORING IN ACCORDANCE WITH THE SOP.

WOP02000/(WIPE_ORG_COLLECT). WAS A WIPE-ORGANICS SAMPLE COLLECTED?

Label	Code	Go To
YES	1
NO	2

PROGRAMMER INSTRUCTIONS

• IF WIPE_ORG_COLLECT = 1, SET SAMPLE_NUMBER = 1 AND GO TO WOP05000.

• OTHERWISE, GO TO WIPE_ORG_NOTCOLLECT.

WOP03000/(WIPE_ORG_NOTCOLLECT). WHY WAS A WIPE-ORGANICS SAMPLE NOT COLLECTED?

Label	Code	Go To
KIT NOT AVAILABLE	1	WIPE_ORG_PRIM_COMMENTS
SUPPLIES PROBLEM	2	WIPE_ORG_PRIM_COMMENTS
RAN OUT OF TIME	3	WIPE_ORG_PRIM_COMMENTS
NOT ENOUGH SPACE	4	WIPE_ORG_PRIM_COMMENTS
REFUSAL	5	WIPE_ORG_PRIM_COMMENTS
OTHER	-5

WOP04000/(WIPE_ORG_NOTCOLLECT_OTH). SPECIFY: ____________________________

PROGRAMMER INSTRUCTIONS

• GO TO WIPE_ORG_PRIM_COMMENTS.

WOP05000. DATE WIPE-ORGANICS SAMPLE COLLECTED:

(WIPE_ORG _COLL_MM) MONTH: |___|___|

                M    M

(WIPE_ORG_COLL_DD) DAY: |___|___|

           D     D

(WIPE_ORG_COLL_YYYY) YEAR: |___|___|___|___|

             Y     Y     Y     Y

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF MM, DD, OR YYYY ARE OUTSIDE CRITERIA DEFINED IN GENERAL PROGRAMMER INSTRUCTIONS.

WOP06000/(SAMPLE_PR_ID). PRIMARY SAMPLE ID:

|E||__|__|__|__|__|__|__|-DP01

WIPE-ORGANICS ID

DATA COLLECTOR INSTRUCTIONS

• ENTER THE WIPE-ORGANICS PRIMARY SAMPLE ID ON THE SAMPLE ID LABEL.

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH DP01.

WOP07000/(WIPE_ORG_ROOM). IN WHICH ROOM WAS THE WIPE-ORGANICS SAMPLE COLLECTED?

Label	Code	Go To
COMMON LIVING AREA	1	WIPE_ORG_SURF
CHILD'S BEDROOM	2	WIPE_ORG_SURF
MOTHER'S BEDROOM	3	WIPE_ORG_SURF
KITCHEN	4	WIPE_ORG_SURF
OTHER	-5

WOP08000/(WIPE_ORG_ROOM_OTH). SPECIFY: __________________________________________

WOP09000/(WIPE_ORG_SURF). WHAT TYPE OF SURFACE WAS WIPED WHEN COLLECTING THE WIPE-ORGANICS SAMPLE?

Label	Code	Go To
SMOOTH SURFACE	1	WIPE_ORG_SURF_MAT
ROUGH SURFACE	2	WIPE_ORG_SURF_MAT
OTHER	-5

WOP10000/(WIPE_ORG_SURF_OTH). SPECIFY: ____________________________________________

WOP11000/(WIPE_ORG_SURF_MAT). WHAT MATERIAL WAS THE SURFACE WIPED WHEN COLLECTING THE WIPE-ORGANICS SAMPLE?

Label	Code	Go To
VINYL	1	WIPE_ORG_ROOM_AREA
LINOLEUM	2	WIPE_ORG_ROOM_AREA
WOOD	3	WIPE_ORG_ROOM_AREA
CORK	4	WIPE_ORG_ROOM_AREA
RUBBER	5	WIPE_ORG_ROOM_AREA
CONCRETE	6	WIPE_ORG_ROOM_AREA
PAINTED	7	WIPE_ORG_ROOM_AREA
TILE	8	WIPE_ORG_ROOM_AREA
OTHER	-5

WOP12000/(WIPE_ORG_SURF_MAT_OTH). SPECIFY: ____________________________________________

WOP13000/(WIPE_ORG_ROOM_AREA). WHERE IN THE ROOM WAS THE WIPE-ORGANICS SAMPLE COLLECTED?

Label	Code	Go To
LESS THAN ONE FOOT FROM WALL	1
ONE FOOT OR MORE FROM WALL	2

WOP14000/(WIPE_ORG_PRIM_COMMENTS). RECORD ANY COMMENTS ABOUT THE WIPE-ORGANICS PRIMARY SAMPLE COLLECTION:

COMMENTS: __________________________________________________________

(TIME_STAMP_WOP_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• IF WIPE_ORG_SAMPLES = 1 OR WIPE_ORG_COLLECT= 2, GO TO TIME_STAMP_WOS_ET.

• IF WIPE_ORG_COLLECT = 1 AND

• IF WIPE_ORG_SUBSAMPLES = 2 ONLY, OR 2 AND 3, GO TO TIME_STAMP_WOD_ST.

• IF WIPE_ORG_SUBSAMPLES = 3 ONLY, GO TO TIME_STAMP_WOS_ST.

• IF WIPE_ORG_SUBSAMPLES = 1 ONLY, 1 AND 2, 1 AND 3, OR 1, 2 AND 3, GO TO TIME_STAMP_WOB_ST.

WIPE-ORGANICS BLANK SAMPLE

(TIME_STAMP_WOB_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

WOB01000/(WIPE_ORG_BLANK_COLLECT). WAS THE WIPE-ORGANICS BLANK SAMPLE COLLECTED?

Label	Code	Go To
YES	1
NO	2

PROGRAMMER INSTRUCTIONS

• IF WIPE_ORG_BLANK_COLLECT = 1, SET SAMPLE_NUMBER = 2 AND GO TO SAMPLE_BL_ID.

• OTHERWISE, GO TO WIPE_ORG_BLANK_NOTCOLLECT.

WOB02000/(WIPE_ORG_BLANK_NOTCOLLECT). WHY WAS THE WIPE-ORGANICS BLANK SAMPLE NOT COLLECTED?

Label	Code	Go To
KIT NOT AVAILABLE	1	WIPE_ORG_BLANK_COMMENTS
SUPPLIES PROBLEM	2	WIPE_ORG_BLANK_COMMENTS
OUT OF TIME	3	WIPE_ORG_BLANK_COMMENTS
OTHER	-5

WOB03000/(WIPE_ORG_BLANK_NOTCOLLECT_OTH). SPECIFY: __________________________

PROGRAMMER INSTRUCTIONS

• GO TO WIPE_ORG_BLANK_COMMENTS.

WOB04000/(SAMPLE_BL_ID). BLANK SAMPLE ID:

|E||__|__|__|__|__|__|__|-DP01

WIPE-ORGANICS BLANK ID

DATA COLLECTOR INSTRUCTIONS

• ENTER THE WIPE-ORGANICS BLANK SAMPLE ID ON THE SAMPLE ID LABEL.

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH DP01.

• DISPLAY SOFT EDIT IF SAMPLE_BL_ID = SAMPLE_PR_ID.

WOB05000/(WIPE_ORG_BLANK_COMMENTS). RECORD ANY COMMENTS ABOUT THE WIPE-ORGANICS BLANK SAMPLE COLLECTION:

COMMENTS: _____________________________________________________

(TIME_STAMP_WOB_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• IF WIPE_ORG_COLLECT= 1 AND

• IF WIPE_ORG_SUBSAMPLES = 1 ONLY, GO TO TIME_STAMP_WOS_ET.

• IF WIPE_ORG_SUBSAMPLES = 1 AND 2, OR 1, 2, AND 3, GO TO TIME_STAMP_WOD_ST.

• IF WIPE_ORG_SUBSAMPLES = 1 AND 3, GO TO TIME_STAMP_WOS_ST.

WIPE-ORGANICS DUPLICATE SAMPLE

(TIME_STAMP_WOD_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

WOD01000/(WIPE_ORG_DUP_COLLECT). WAS THE WIPE-ORGANICS DUPLICATE SAMPLE COLLECTED?

Label	Code	Go To
YES	1
NO	2

PROGRAMMER INSTRUCTIONS

• IF WIPE_ORG_DUP_COLLECT = 1, SET SAMPLE_NUMBER = 3, AND GO TO SAMPLE_DP_ID.

• OTHERWISE, GO TO WIPE_ORG_DUP_NOTCOLLECT.

WOD02000/(WIPE_ORG_DUP_NOTCOLLECT). WHY WAS THE WIPE-ORGANICS DUPLICATE SAMPLE NOT COLLECTED?

Label	Code	Go To
KIT NOT AVAILABLE	1	WIPE_ORG_DUP_COMMENTS
SUPPLIES PROBLEM	2	WIPE_ORG_DUP_COMMENTS
OUT OF TIME	3	WIPE_ORG_DUP_COMMENTS
NOT ENOUGH SPACE	4	WIPE_ORG_DUP_COMMENTS
REFUSAL	5	WIPE_ORG_DUP_COMMENTS
OTHER	-5

WOD03000/(WIPE_ORG_DUP_NOTCOLLECT_OTH). SPECIFY: ____________________________

PROGRAMMER INSTRUCTIONS

• GO TO WIPE_ORG_DUP_COMMENTS.

WOD04000/(SAMPLE_DP_ID). DUPLICATE SAMPLE ID:

|E||__|__|__|__|__|__|__|-DP01

WIPE-ORGANICS DUPLICATE ID

DATA COLLECTOR INSTRUCTIONS

• ENTER THE WIPE-ORGANICS DUPLICATE SAMPLE ID ON THE SAMPLE ID LABEL.

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH DP01.

• DISPLAY SOFT EDIT IF SAMPLE_DP_ID = SAMPLE_PR_ID AND/OR SAMPLE_BL_ID.

WOD05000/(WIPE_ORG_DUP_SURF). WHAT TYPE OF SURFACE WAS WIPED WHEN COLLECTING THE WIPE-ORGANICS DUPLICATE SAMPLE?

Label	Code	Go To
SMOOTH SURFACE	1	WIPE_ORG_DUP_SURF_MAT
ROUGH SURFACE	2	WIPE_ORG_DUP_SURF_MAT
OTHER	-5

WOD06000/(WIPE_ORG_DUP_SURF_OTH). SPECIFY: ____________________________________________

WOD07000/(WIPE_ORG_DUP_SURF_MAT). WHAT MATERIAL WAS THE SURFACE WIPED WHEN COLLECTING THE WIPE-ORGANICS DUPLICATE SAMPLE?

Label	Code	Go To
VINYL	1	WIPE_ORG_DUP_ROOM_AREA
LINOLEUM	2	WIPE_ORG_DUP_ROOM_AREA
WOOD	3	WIPE_ORG_DUP_ROOM_AREA
CORK	4	WIPE_ORG_DUP_ROOM_AREA
RUBBER	5	WIPE_ORG_DUP_ROOM_AREA
CONCRETE	6	WIPE_ORG_DUP_ROOM_AREA
PAINTED	7	WIPE_ORG_DUP_ROOM_AREA
TILE	8	WIPE_ORG_DUP_ROOM_AREA
OTHER	-5

WOD08000/(WIPE_ORG_DUP_SURF_MAT_OTH). SPECIFY: ____________________________________________

WOD09000/(WIPE_ORG_DUP_ROOM_AREA). WHERE IN THE ROOM WAS THE WIPE-ORGANICS DUPLICATE SAMPLE COLLECTED?

Label	Code	Go To
LESS THAN ONE FOOT FROM WALL	1
ONE FOOT OR MORE FROM WALL	2

WOD10000/(WIPE_ORG_DUP_COMMENTS). RECORD ANY COMMENTS ABOUT THE WIPE-ORGANICS DUPLICATE SAMPLE COLLECTION:

COMMENTS: _____________________________________________________

(TIME_STAMP_WOD_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• IF WIPE_ORG_COLLECT= 1 AND?

• IF WIPE_ORG_SUBSAMPLES = 2 ONLY, OR 1 AND 2, GO TO TIME_STAMP_WOS_ET.

• IF WIPE_ORG_SUBSAMPLES = 2 AND 3 OR 1, 2, AND 3, GO TO TIME_STAMP_WOS_ST.

WIPE-ORGANICS SPIKE SAMPLE

(TIME_STAMP_WOS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

WOS01000/(WIPE_ORG_SPIKE_COLLECT). WAS THE WIPE-ORGANICS SPIKE SAMPLE INCLUDED?

Label	Code	Go To
YES	1
NO	2

PROGRAMMER INSTRUCTIONS

• IF WIPE_ORG_SPIKE_COLLECT = 1, SET SAMPLE_NUMBER = 4 AND GO TO SAMPLE_SP_ID.

• OTHERWISE, GO TO WIPE_ORG_SPIKE_NOTCOLLECT.

WOS02000/(WIPE_ORG_SPIKE_NOTCOLLECT). WHY WAS THE WIPE-ORGANICS SPIKE SAMPLE NOT INCLUDED?

Label	Code	Go To
SPIKE NOT AVAILABLE	1	WIPE_ORG_SPIKE_COMMENTS
OUT OF TIME	2	WIPE_ORG_SPIKE_COMMENTS
OTHER	-5

WOS03000/(WIPE_ORG_SPIKE_NOTCOLLECT_OTH). SPECIFY: ________________________________

WOS04000/(SAMPLE_SP_ID). SPIKE SAMPLE ID:

|E||__|__|__|__|__|__|__|-DP01

WIPE-ORGANICS SPIKE ID

DATA COLLECTOR INSTRUCTIONS

• ENTER THE WIPE-ORGANICS SPIKE SAMPLE ID ON THE SAMPLE ID LABEL.

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH DP01.

• DISPLAY SOFT EDIT IF SAMPLE_SP_ID = SAMPLE_PR_ID, SAMPLE_BL_ID AND/OR SAMPLE_DP_ID.

WOS05000/(WIPE_ORG_SPIKE_COMMENTS). RECORD ANY COMMENTS ABOUT THE WIPE-ORGANICS SPIKE SAMPLE COLLECTION:

COMMENTS: _____________________________________________________

(TIME_STAMP_WOS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

Public reporting burden for this collection of information is estimated to average 1 minute 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 (0925-0593*).  Do not return the completed form to this address.