Form 0920-0906 Appndx D9_6_12mo_C7-12 7-1-2011

Green Housing Study Form Approved

OMB No. 0920-0906

Appendix D10 - Time/Activity Questionnaire (Children with Asthma 7-12 years)

Child’s ID# ______________

Household ID# _____________

Green Housing Study

Time/Activity Questionnaire

(Children with Asthma 7-12 years)

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).

Interviewer Initials _______ Date: ___________

1. Observation point (Circle One):

1. Baseline

2. Baseline part 2

3. 6-month follow-up (post-remediation)

4. 12-month follow-up (post-remediation)

2. In the days that we were sampling your air inside your home, where was [Child’s name] during most of the daytime (6am-6pm)?

(If evenly divided between two or more locations, please circle all that apply)

Day 1: a. Inside this home

2. Inside a building at childcare or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (recreation or other activities)

Day 2: a. Inside this home

2. Inside a building at childcare or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (recreation or other activities)

Day 3: a. Inside this home

2. Inside a building at childcare or school or other location

3. In transit (bus, car, subway, truck)

4. Outdoors (recreation or other activities)

Day 4: a. Inside this home

2. Inside a building at childcare or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (recreation or other activities)

Day 5: a. Inside this home

2. Inside a building at childcare or school or other location

3. In transit (bus, car, subway, train)

4. Outdoors (recreation or other activities)

3. In the days that we were sampling your air inside your home, where was [Child’s name] during most of the nighttime (6pm-6am)?

(If evenly divided between two or more locations, please circle all that apply)

Day 1: a. Inside this home

2. Inside a building at another location

3. In transit (bus, car, subway, truck)

4. Other

Day 2: a. Inside this home

2. Inside a building at another location

3. In transit (bus, car, subway, truck)

4. Other

Day 3: a. Inside this home

2. Inside a building at another location

3. In transit (bus, car, subway, truck)

4. Other

Day 4: a. Inside this home

2. Inside a building at another location

3. In transit (bus, car, subway, truck)

4. Other

Day 5: a. Inside this home

2. Inside a building at another location

3. In transit (bus, car, subway, truck)

4. Other

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