Form 0920-0906 Appndx D3_Baseline_Pt 2 HomeChar 10-10-2011

Green Housing Study Form Approved

OMB No. 0920-0906

Appendix D3 Baseline (Part 2) Questionnaire (Home Characteristics) Household ID# _____________

Green Housing Study

Baseline (Part 2) Questionnaire

(Home Characteristics)

Public reporting burden of this collection of information is estimated to average 5 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 (0920-0906).

1. DATE OF INTERVIEW _____ /_____ /_____ (mm/dd/yyyy)

2. INTERVIEWER INITIALS (max 3) _____ _____ _____

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3. Was your home recently renovated by the owner/ housing authority?

Y N

If NO, then skip to question #10

If YES, specify:

3.1 Have all renovation activities inside your home been completed? Y N

(If NO and only minor changes other than painting will occur, then continue; otherwise, STOP and re-schedule home visit)

3.2 When were all renovation activities completed?_____ /_____ /_____ (mm/dd/yyyy)

(If only minor changes (painting is considered a major change) will occur, then enter tomorrow’s date, so that we know that the renovations are not yet complete)

4. During the renovation, did you/your family live in this home while it was being renovated?

Y N

If NO, then skip to next question

If YES specify living situation

a. Stayed in home during entire renovation

b. Stayed in home during some of renovation

5. During the renovation, did your home have new flooring installed or refinished?

Y N DK

If NO, then skip to next question

If YES specify flooring (please circle all that apply)

1. Wood or wood laminate

2. Linoleum or other vinyl

3. Ceramic or porcelain

4. Concrete

5. Stone (Slate or terracotta)

6. Other

6. During the renovation, was any part of your home painted?

Y N DK

If NO, then skip to next question

If YES specify:

1. Was child’s bedroom painted? Y N DK N/A

2. Was mother/ primary caregiver’s bedroom painted? Y N DK N/A

3. Was kitchen painted? Y N DK

4. Was any bathroom painted? Y N DK

5. Was living room painted? Y N DK N/A

7. During the renovation, was spray foam insulation installed?

Y N DK N/A

8. During the renovation, did your home have new kitchen cabinets installed or refinished?

Y N DK

9. During the renovation, did your home have new bathroom cabinets or vanity installed or refinished?

Y N DK

10. Have you painted any rooms in your home?

1. No

2. Yes, in the past week,

3. Yes, in the past month

4. Other

11. Have you changed any carpeting (including rugs) in your home?

1. No

2. Yes, in the past week,

3. Yes, in the past month

4. Other

If YES, circle ALL that apply:

1. Added carpet/ rug

2. Removed carpet/rug

(Note: replacing carpeting means that both options should be circled)

12. Have you added/removed any piece of furniture in your home?

1. No

2. Yes, in the past week,

3. Yes, in the past month

4. Other

If YES, circle ALL that apply:

1. Added fabric-covered furniture

2. Removed fabric-covered furniture

3. Added wood (e.g, solid wood, particle board) furniture

4. Removed wood (e.g, solid wood, particle board) furniture

13. Have you added or removed any mattresses?

1. No

2. Yes, in the past week,

3. Yes, in the past month

4. Other

If YES, please specify:

1. [Child’s name] mattress? Y N N/A

2. Mother/ Primary caregiver’s mattress? Y N N/A

14. Was the kitchen floor mopped in the past 3 days? Y N

15. Does your home have exhaust fans in the bathroom(s)? Y N DK

If YES, then ask

15.1 In the bathroom where you shower or bathe, does the exhaust fan work? Y N DK

If YES, then ask

15.1.1 How frequently do you use it when showering or bathing?

1. Never

2. Sometimes

3. All the time

16. What type of stove do you have?

1. Gas

2. Electric

3. n/a

17. What kind of air conditioner do you use?

(Circle ALL that apply)

1. Central unit

2. Window or Portable/free-standing unit

3. Swamp cooler/evaporative cooler

4. n/a

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