Screening Survey Bhutan Burm

Eligibility Screening Survey, Bhutanese and Burmese

New York State Department of Health

The Healthy Fishing Community Project in Syracuse, NY

August 7, 2014

Revised June 1, 2015

Readability, calculated using the Flesch-Kinkaid Readability Option in Microsoft Word, has been determined at the 8^th grade level

Form Approved

OMB No. 0923-0052

Exp. Date 4/30/2017

Instructions: If participant is not a seed, ask questions #1-3. If the participant is a seed, begin with question #4.

1. a. If Burmese: Were you born in Burma or in a refugee camp in Thailand or Malaysia?

 Yes  go to #2

 No END OF SURVEY. “…you are not eligible to participate…”

b. If Bhutanese: Were you born in Nepal or Bhutan?

 Yes  go to #2

 No END OF SURVEY. “…you are not eligible to participate…”

2. What is your relationship to the person who gave you the coupon?

 Friend or acquaintance  go to #3

 Relative, does not live with me  go to #3

 Co-worker, supervisor, etc.  go to #3

 Relative or household member, lives with me  END OF SURVEY.

 Stranger END OF SURVEY.

If END OF SURVEY: “I am sorry, but you are not eligible to participate in this project. Thank you for coming in.”

3. Have you or anyone you live with already participated in this project?

 Yes  END OF SURVEY. “…you are not eligible to participate…”

 No go to #4

 Don’t know  Describe project and determine if the individual has already participated. (Verify later from the database of participants.)

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).

4. How old are you? ______ years

If 18 years through 69 years of age  go to #5.

If less than 18 years or more than 69 years old “…you are not eligible to participate…”

5.  Male  Female

6. Have you lived in the Syracuse area for at least one year?

 Yes  go to #7

 No END OF SURVEY.

 Don’t know  END OF SURVEY.

If END OF SURVEY: “…you are not eligible to participate…”

7. In the past 12 months, which of the following bodies of water did you fish or eat fish from?

SHOW MAP.

(Check all that apply.)

 Onondaga Lake (including surrounding creeks)

 Seneca River

 Oswego River

 Lake Ontario

 Know it was from nearby water(s) but can’t remember the name

If one or more bodies of water or “nearby water” are checked  go to #8

 None

 Don’t know

If none or don’t know  END OF SURVEY. “…you are not eligible to participate…”

8. In the past 12 months, how many times did you eat fish caught in the bodies of water listed in #7?

____ times

 If ≥12 times: “You are eligible to participate in this project.”

 If <12 times: “…you are not eligible to participate…”

 Don’t know  “…you are not eligible to participate…”

END OF SURVEY