Biom Questionnaire Bhutan Burm

Attachment 8c

Biomonitoring Interview Questionnaire, Bhutanese and Burmese

New York State Department of Health

The Healthy Fishing Community Project in Syracuse, NY

October 21, 2014

Revised June 1, 2015

Readability, calculated using the Flesch-Kinkaid Readability Option in Microsoft Word, has been determined at the 3rd grade level without country names

Form Approved

OMB No. 0923-0052

Exp. Date 04/30/2017

BACKGROUND INFORMATION

1. What is your full name? (Use NYS ID card)

Full name:___________________________________________________________

Other names:__________________________________________________________

2. Sex

___Male

___ Female

3. What is your birth date? (Use NYS ID card.)

MONTH	DAY	YEAR

4. Age: _____ years

5. Do you have a phone number where we can reach you? (This can be the phone number of a friend, relative, or someone who will know how to find you )

___ Yes _____________________ Home Work Cell Other: ____________

_____________________ Home Work Cell Other: ____________

___ No

___ Don’t know

___ Refused

6. Do you have an email address?

___ Yes  What is it? ________________________________

___ No

___ Don’t know

___ Refused

Public reporting burden of this collection of information is estimated to average 45 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).

Script: We would like to give you the results of the blood and urine testing. When you receive the results, someone will help explain them to you.

7. Do you want your blood and urine results sent to your doctor or clinic?

___ Yes  go to #8

___ No  go to #9

___ Don’t have a doctor/clinic Go to #9.

___ Don’t know  Go to #9.

___ Refused

8. What is your doctor or clinic’s name, telephone number, and address?

Name of doctor or clinic: ______________________________

Telephone number: _________________

Address: ___________________________________________

DEMOGRAPHICS

9. In what country were you born?

___ United States

___ Burma/Myanmar

___ Thailand

___ Malaysia

___ Bhutan

___ Nepal

___ Other country  Specify: _________________________

___ Don’t know

___ Refused

10. What is your ethnicity or tribe?

___ Nepali (Bhutanese)

___ Burman

___ Chin

___ Kachin

___ Karenni

___ Karen

___ Mon

___ Rakhine

___ Other  Specify: _________________________

___ Don’t Know

___ Refused

REPRODUCTIVE HISTORY

FEMALES only. If MALE  go to 17

11. Are you pregnant?

___ Yes  go to #12

___ No  go to #13

___ Don’t know  go to #13

___ Refused  go to #13

12. When is your due date?

Month	DAY	YEAR

___ Don’t know

___ Refused

13. Have you given birth?

___ Yes, How many children? ______________

___ No  go to #17

___ Don’t know  go to #17

___ Refused  go to #17

14. Have you ever breastfed any children?

___ Yes, How many children? _______________

___ No  go to #17

___ Don’t know  go to #17

___ Refused  go to #17

15. Are you breastfeeding any children now?

___ Yes

___ No

___ Don’t know

___ Refused

16. Tell me about the children you have breastfed from the first to the most recent child.

Birth order	Birth Year (YYYY)	Birthplace (country, city / refugee camp)	At what age did they stop breast feeding?	Number of months breastfeeding?
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th

HOUSEHOLD INFORMATION

17. What is your address?

Street Number: ____________________

Street Name:_______________________________________________

Apartment Number: ______________

Unit: ____________________ (“upper” or “lower” )

City: _____________________ State: _______ ZIP Code: _____________

18. Including yourself and any children, how many people currently live at your address?

___Total number: _____________

___ Lives alone  go to #21

___ Don’t know  go to #21

___ Refused  go to #21

19. How many people who live with you are female and how many are male?

Female: _____

Male: _____

___ Don’t know go to #21

___ Refused  go to #21

20. How many people who live with you are under the age of 15?

Number under 15 years: _____

___ Don’t know  go to #21

___ Refused  go to #21

RESIDENTIAL HISTORY

Script: Please answer the following questions about how long you have lived in the Syracuse area and in other places in the past.

21. How long have you lived in the United States?

_____ years and _____ months

___ Don’t know

___ Refused

22. How long have you lived in the Syracuse area, New York?

_____ years and _____ months

___ Don’t know

___ Refused

23. Have you lived in other cities in the United States other than the Syracuse area?

___ Yes  go to #24

___ No  go to #25

___ Don’t know  go to #25

___ Refused  go to #25

24. What other cities in the United States have you lived in?

City #1 (specify): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

City #2 (specify): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

25. Did you live in any refugee camps?

___ Yes  go to #26

___ No  go to #27

___ Don’t know  go to #27

___ Refused  go to #27

26. Where were the refugee camps?

Camp #1 (location): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

Camp #2 (location): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

27. Did you live in any other countries, excluding the countries where you lived in a refugee camp?

___ Yes  go to #28

___ No  go to #29

___ Don’t know  go to #29

___ Refused  go to #29

28. What other countries did you live in?

Country #1 (location): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

Country #2 (location): ________________________

How long did you live there? _____ years and _____ months

___ Don’t know

___ Refused

How often did you eat fish there?

___ times per (circle one) week month year

___ Don’t know

___ Refused

CONSUMED FISH

29. Have you eaten fish or shellfish in the past week?

___ Yes  go to #30

___ No  go to #31

___ Don’t know  go to #31

___ Refused  go to #31

30. 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

___ Don’t know

___ Refused

Script: The next group of questions is about the following nearby waters. (READ THE LIST AND SHOW PICTURES)

Lake Ontario

Oswego River

Seneca River

Onondaga Lake and surrounding creeks including Sawmill Creek, Onondaga Creek, Ninemile Creek and Bloody Brook

31. Which of these nearby waters have you eaten fish from? (Check all that apply.)

___ Lake Ontario

___ Oswego River

___ Seneca River

___ Onondaga Lake and surrounding creeks including Sawmill Creek, Onondaga Creek, Ninemile Creek, Ley Creek, and Bloody Brook

___ Don’t know

___ Refused

___ None

32. How do you get your fish from these waters? This is private information that will not be shared. (Check all that apply)

___ Catch it

___ Received as a gift from friends/family

___ Collect from people fishing

___ Buy it down by the river/lake

___ Collect it from the water or ground (without fishing for it)

___ Don’t Know

___ Refused

33. Do you freeze the fish caught from nearby waters to eat later?

___ Yes

___ No

___ Don’t know

___ Refused

34. How often did you eat fish caught from these nearby waters in the past 12 months? This includes frozen fish.

In summer? (months: June, July, August; description: when it’s hot outside)

___ times eats fish per (circle one) day week month

___ Does not eat during these months

___ Don’t know

___ Refused

In fall? (months: September, October; description: when it’s cold outside but not snowing)

___ times eats fish per (circle one) day week month

___ Does not eat during these months

___ Don’t know

___ Refused

In winter? (months: November, December, January, February, March; description: when there is snow on the ground)

___ times eats fish per (circle one) day week month

___ Does not eat during these months

___ Don’t know

___ Refused

In spring? (months: April, May; description: when it’s rainy, cool, but there’s no snow)

___ times eats fish per (circle one) day week month

___ Does not eat during these months

___ Don’t know

___ Refused

35. Does anyone else in your household, including children, eat fish from these nearby waters?

___ Yes, Number: _____

___ No  go to #37.

___ Don’t know  go to #37

___ Refused  go to #37

36. How many people in your house that eat fish caught from nearby waters are children under 15 years old?

 Number of children under 15 years: ___

___ None

___ Don’t know

___ Refused

37. Which of the following fish caught from nearby waters have you eaten in the past 12 months? SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

___ Alewife ___ Gizzard shad	___ Rudd ___ Golden shiner ___ Emerald shiner ___ Spot fin shiner	___ Short head redhorse ___ Greater redhorse ___ Silver redhorse
___ Chinook “King” salmon ___ Coho salmon ___ Atlantic salmon	___ Muskellunge/ Tiger muskie ___ Northern pike ___ Chain pickerel ___ Bowfin	___ Walleye ___ Yellow perch
___ Lake trout ___ Rainbow trout/Steelhead ___ Brown Trout ___ Brook Trout	___ Lake sturgeon	___ White bass ___ White perch
	___ Common carp ___ Long nose gar ___ Goldfish ___ Green sunfish	___ Largemouth (black) bass smaller than 15 inches long ___ Largemouth (black) bass 15 inches long or larger ___ Smallmouth (black) bass smaller than 15 inches long ___ Smallmouth (black) bass 15 inches long or larger
___ American eel	___ Freshwater drum “Sheephead”	___ Rock bass ___ Pumpkinseed/Sunfish ___ Black crappie ___ Bluegill
___ Quillback	___ Northern hog sucker ___ White sucker
___ Rainbow smelt	___ Channel catfish ___ Brown bullhead ___ Yellow bullhead ___ Black bullhead
___ Round goby ___ Blunt-nose minnow ___ Fathead minnow ___ Long nose dace
Other (specify): __________________ Other (specify): __________________ Other (specify): __________________ Other (specify): __________________

38. How do you usually prepare the fish before it is cooked? (Check all that apply.)

Smaller fish (smaller than your hand)

___ Removes scales (but not skin)

___ Cut off head

___ Remove guts

___ Remove skin

___ Fillet (cut the large piece off the side)

___ Cut off belly fat

___ Keeps whole, does not remove parts of fish before cooking

___ Don’t know

___ Refused

Larger fish (larger than your hand)

___ Removes scales (but not skin)

___ Cut off head

___ Remove guts

___ Remove skin

___ Fillet (cut the large piece off the side)

___ Cut off belly fat

___ Keeps whole, does not remove parts of fish before cooking

___ Don’t know

___ Refused

39. What parts of fish do you usually eat? (Check all that apply.)

Smaller fish (smaller than your hand)

___ Whole with head

___ Whole without head

___ Fillet (cut the large piece off the side)

___ Guts/innards

___ Skin

___ Head

___ Other->Specify: _____________________________________________

___ Don’t know

___ Refused

Larger fish (larger than your hand)

___ Whole with head

___ Whole without head

___ Fillet (cut the large piece off the side)

___ Guts/innards

___ Skin

___ Head

___ Other->Specify: _____________________________________________

___ Don’t know

___ Refused

40. How is the fish usually cooked? (Check all that apply.)

Smaller fish (smaller than your hand)

___ Fish paste

___ Dried

___ Pickled

___ Smoked

___ Pan fried

___ Deep fried

___ Boiled/poached

___ Soup / curry

___ Grilled / roasted

___ Baked/broiled in oven

___ Eaten raw

___ Don’t know

___ Refused

Larger fish (larger than your hand)

___ Fish paste

___ Dried

___ Pickled

___ Smoked

___ Pan fried

___ Deep fried

___ Boiled/poached

___ Soup / curry

___ Grilled / roasted

___ Baked/broiled in oven

___ Eaten raw

___ Don’t know

___ Refused

FISH PASTE

Script: I'm going to ask you some questions about fish paste [“nya u” (Karen) or “ngape” (Burmese)]

41. Do you eat fish paste?

___ Yes  How often?___ times per (circle one) week month year

___ No  go to #46

___ Don’t know  go to #46

___ Refused  go to #46

42. Do you eat store bought or homemade fish paste?

___ Homemade

___ Store bought  go to #46

___ Don’t know  go to #46

___ Refused  go to #46

43. Is the homemade fish paste made from fish caught in nearby waters?

___ Yes

___ No  go to #46

___ Don’t know  go to #46

___ Refused  go to #46

44. What kinds of fish from nearby waters is the fish paste made from?

SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

___ Alewife ___ Gizzard shad	___ Rudd ___ Golden shiner ___ Emerald shiner ___ Spot fin shiner	___ Short head redhorse ___ Greater redhorse ___ Silver redhorse
___ Chinook “King” salmon ___ Coho salmon ___ Atlantic salmon	___ Muskellunge/ Tiger muskie ___ Northern pike ___ Chain pickerel ___ Bowfin	___ Walleye ___ Yellow perch
___ Lake trout ___ Rainbow trout/Steelhead ___ Brown Trout ___ Brook Trout	___ Lake sturgeon	___ White bass ___ White perch
	___ Common carp ___ Long nose gar ___ Goldfish ___ Green sunfish	___ Largemouth (black) bass smaller than 15 inches long ___ Largemouth (black) bass 15 inches long or larger ___ Smallmouth (black) bass smaller than 15 inches long ___ Smallmouth (black) bass 15 inches long or larger
___ American eel	___ Freshwater drum “Sheephead”	___ Rock bass ___ Pumpkinseed/Sunfish ___ Black crappie ___ Bluegill
___ Quillback	___ Northern hog sucker ___ White sucker
___ Rainbow smelt	___ Channel catfish ___ Brown bullhead ___ Yellow bullhead ___ Black bullhead
___ Round goby ___ Blunt-nose minnow ___ Fathead minnow ___ Long nose dace
Other (specify): __________________ Other (specify): __________________ Other (specify): __________________ Other (specify): __________________

45. What parts of the fish is the homemade fish paste made from? (Check all that apply.)

___ Whole fish

___ Flesh and skin only

___ Flesh only

___ Whole fish with head and tail removed

___ Other: (specify) ___________________________

___ Don’t know

___ Refused

WILD BIRDS AND ANIMALS

46. In the past year, have you eaten any of these wild birds or animals? Circle Answers

Waterfowl (ducks or geese) Crows or other scavenger birds Deer Frogs or toads

Rats or Mice Squirrels Rabbits Groundhogs

___ Other (specify): ______________________________

___ None

___ Don’t know

___ Refused

STORE BOUGHT FISH

Script: The following questions are about fish you have eaten that were bought at a store, restaurant, fish vendor, open air market, Asian market or supermarket?

47. Which of the following fish have you eaten at least five times in your life? (Check all the species that apply)

___ Grouper

___ Shark

___ Swordfish

___ Salmon (including canned)

___ Tuna (not canned)

___ Tuna (canned)

___ Shrimp

___ Snails

___ Mussels

___ None  go to #50

___ Don’t know  go to #50

___ Refused  go to #50

Note: Question 48 should be asked for EACH fish answered in question 47

48. How many years did you eat [fish/shellfish]?

	Grouper	Shark	Swordfish	Salmon (including canned)	Tuna (not canned)	Tuna (canned)	Shrimp	Snails	Mussels
Years
Don’t know
Refused

Note: Question 49 should be asked for EACH fish answered in question 47

49. In the past year, how many times did you eat [fish/shellfish]?

	Grouper	Shark	Swordfish	Salmon (including canned)	Tuna (not canned)	Tuna (canned)	Shrimp	Snails	Mussels
Times per	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year	____ (circle one) Week Month Year
Don’t know
Refused

___

STORE BOUGHT FOODS

Script: The following questions are about other foods that you may have eaten in the past 12 months. We want to know about the foods you eat that have a lot of animal fat.

In the past 12 months, how often did you eat meals with …..? SHOW CARD.

50. Whole eggs?(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

51. Whole milk products (including 2% milk)? (If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

52. Poultry meat like chicken and turkey?(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

53. Red meat like beef and pork? (If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

WORK HISTORY AND EDUCATION

54. Do you work?

___ Yes

___ No  go to #59

___ Don’t know  go to #59

___ Refused  go to #59

55. Do you work full time or part time?

___ Full time

___ Part time

___ Don’t know

___ Refused

56. What is your current job?

Title_______________________________

Where do you work? ___________________________________________

How many hours a week do you work? _____ hours per week

How much are you paid per hour? $ _____ per hour

57. Do you have a second job?

___ Yes  go to #58

___ No  go to #59

___ Don’t know  go to #59

___ Refused  go to #59

58. What is your second job?

Title_______________________________

Where do you work? ___________________________________________

How many hours a week do you work? _____ hours per week

How much are you paid per hour? $ _____ per hour

59. Have you worked at any (other) job in the past year?

___ Yes  go to #60

___ No  go to #62

___ Don’t know  go to #62

___ Refused  go to #62

60. Did you work full time or part time?

___ Full time

___ Part time

___ Don’t know

___ Refused

61. What was this other job?

Title_______________________________

Where do you work? ___________________________________________

How many hours a week do you work? _____ hours per week

How much are you paid per hour? $ _____ per hour

62. Does anyone in your household receive food stamps?

___ Yes

___ No

___ Don’t know

___ Refused

63. Does anyone in your household receive WIC services?

___ Yes

___ No

___ Don’t know

___ Refused

64. How many years of school have you completed?

Number of years: _____

___ None  go to #66

___ Don’t know go to #66

___ Refused  go to #66

65. Have you ever attended school in the United States?

___ Yes

___ No

___ Don’t know

___ Refused

66. Do you read?

___ Yes  Which language? (specify) ____________________________________________

___ No

___ Don’t know

___ Refused

LIFESTYLE

Script: The next group of questions will be about any behaviors or customs you have that could expose you to some contaminants found in Great Lakes fish.

67. Do you swim, dive, or wade in any of these local bodies of water? (READ THE LIST AND SHOW PICTURES)

___ Yes. How many times in the past year? ______

___ No

___ Don't know

___ Refused

68. On most days, do you take or use any of the following (Check all that apply.)

___ Herbal medicine or supplements  Specify:______________________

___ Fish oil

___ Store-bought Betel nut

___ Natural or hand-made Betel nut

___ None

___ Don’t know

___ Refused

69. Do you use a homemade or store-bought yellow powder/cream called Thanakar/Thanakha?

___ Homemade  go to #70

___ Store bought  go to #70

___ No  go to #71

___ Don’t know  go to #71

___ Refused  go to # 71

70. How often do you use Thanakar?

___ times per (circle one) week month year

___ Don’t know

___ Refused

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

___ Yes  go to #72

___ No  go to #76

___ Don’t know  go to #76

___ Refused  go to #76

72. Do you smoke cigarettes now?

___ Yes  go to 74

___ No  go to 73

___ Don’t know  go to #73

___ Refused  go to #76

73. How long has it been since you last smoked cigarettes regularly?

_____ months or _____ years  go to #76

74. How often do you smoke cigarettes?

___ Daily

___ Weekly  go to #76

___ Monthly  go to #76

___ Don’t know  go to #76

___ Refused  go to #76

75. How many cigarettes do you smoke per day? (1 pack=20 cigarettes)

___ 1-5 per day

___ 6-10 per day

___ 11-20 per day (>1/2 and <1 pack per day)

___ >20 per day (>1 pack per day)

___ Don’t know

___ Refused

76. Do you use chewing tobacco or snuff?

___ Yes  go to #77

___ No  go to #78

___ Don’t know  go to #78

___ Refused  go to #78

77. How often do you use chewing tobacco or snuff?

___ Daily

___ Weekly

___ Monthly

___ Don’t know

___ Refused

FISHING INFORMATION

78. Have you heard about health advice on eating fish from nearby waters?

___ Yes  From who or where did you hear it? ____________________________

___ No

___ Don’t know

___ Refused

END OF INTERVIEW

34