Biomonitoring Questionnaire Sub Anglers

Attachment 8g

Biomonitoring Interview Questionnaire, Subsistence Anglers

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 4/30/2017

CONTACT INFORMATION

1. What is your full name?

First: __________________ Last: __________________ Middle initial: ___

___ Refused

2. Do you have an email address?

___ Yes  What is it? ________________________________________

___ No

___ Don’t know

___ Refused

3. 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: _________

_____________________ Home Work Cell Other: _________

___ No

___ Don’t know

___ Refused

4. What is your street address?

Street Number: ______ Street Name:_____________________ Unit: ____

City: ___________________________ State: _______ ZIP Code: ________

5. Is your mailing address different from your street address?

___ Yes  What is your mailing address?

Street Number: ______ Street Name:_____________________ Unit: ____

City: ___________________________ State: _______ ZIP Code: _______

___ No

___ Don’t know

___ Refused

Public reporting burden of this collection of information is estimated to average 30 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).

Page 2

6. If you want your blood and urine test results sent to your doctor, what is his/her name, phone number, and address?

Name of doctor: ______________________________

Telephone number: _________________

Address: _____________________________________________________________

SEX AND AGE

Script. Now we will begin the interview. The first part is about your background. It will help us compare your answers to other participants’ answers.

7. Indicate whether the person is male or female. If unsure, ask his/her sex.

___ Male

___ Female

8. What is your birthdate?

____ / _____ / _______  So you are _____ years old?

mm dd yyyy

ETHNICITY AND RACE

9. Do you consider yourself to be Hispanic or Latino?

___ Yes

___ No

___ Don’t know

___ Refused

10. What race do you consider yourself to be? (Check all that apply.)

___ White

___ Black or African American

___ Asian

___ Native Hawaiian or Other Pacific Islander

___ American Indian or Alaska Native

___ Other  Specify: _______________

___ Don’t know

___ Refused

Page 3

RESIDENTIAL HISTORY

Script: Next, I will ask you where you have lived.

11. How long have you lived at your current address?

___ Entire life

(If less than 1 year, enter 0 years and number of months. If full years reported, enter number of years and 0 months.)

_____ years _____ months

12. When was this home built?

___ 1978 or after

___ 1950 to 1977

___ Before 1950

___ Don’t know

___ Refused

13. How long have you lived in Syracuse?

___ Entire life

(If less than 1 year, enter 0 years and number of months. If full years reported, enter number of years and 0 months.)

_____ years _____ months

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.

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

___ Herbal medicine or supplements  Specify: _________________________________

___ Fish oil

___ None

___ Don’t know

___ Refused

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

___ Yes (Ever smoker)  go to #16

___ No (Never smoker)  go to #20

___ Don’t know  go to #20

___ Refused  go to #20

Page 4

16. (Ever smoker) Do you smoke cigarettes now?

___ Yes (Current smoker)  go to #18

___ No (Former smoker)  go to #17

___ Don’t know  go to #20

___ Refused  go to #20

17. (Former smoker) How long has it been since you last smoked cigarettes regularly?

_____ months or _____ years  go to #20

18. (Current smoker) How often do you smoke cigarettes?

___ Daily (Daily smoker)  go to #19

___ Weekly  go to #20

___ Monthly  go to #20

___ Don’t know  go to #20

___ Refused  go to #20

19. (Daily smoker) 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

20. Do you use chewing tobacco or snuff?

___ Yes  go to #21

___ No  go to #22

___ Don’t know  go to #22

___ Refused  go to #22

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

___ Daily

___ Weekly

___ Monthly

___ Don’t know

___ Refused

Page 5

PERSONAL ACTIVITIES

Script: The next questions are about activities or interests done as hobbies. You may do these activities for fun, to earn money, or to keep up your house.

22. In the past 12 months, have you or someone else in your household done any of the following activities? SHOW CARD

___ Yes  go to #23

___ No  go to # 25 (if female) #29 (if male)

___ Don’t know  go to #25 (if female) or #29 (if male)

___ Refused  go to #25 (if female) or #29 (if male)

23. Tell me which activities you did in the last 12 months.

SHOW CARD. (Check all that apply.)

___ Dyeing material ___ Metal work ___ None

___ Electronics assembly ___ Painting and glazing ___ Don’t know

___ Gardening or farming ___ Printmaking ___ Refused

___ Glass crafting ___ Woodworking

___ Leather crafting

24. Tell me which activities another household member has done in your home the last 12 months.

SHOW CARD. (Check all that apply.)

___ Dyeing material ___ Metal work

___ Electronics assembly ___ Painting and glazing ___ None

___ Gardening or farming ___ Printmaking ___ Don’t know

___ Glass crafting ___ Woodworking ___ Refused

___ Leather crafting

Page 6

REPRODUCTIVE HISTORY

If MALE  go to #29

If FEMALE  go to #25

25. Are you pregnant?

___ Yes  go to #26

___ No  go to #27

___ Don’t know  go to #27

___ Refused  go to #27

26. How many weeks pregnant are you?

______ weeks  go to #27

___ Don’t know  go to #27

___ Refused  go to #27

27. How many children have you given birth to?

(If NONE, enter 0  go to #29)

______ child/children  go to #28

___ Don’t know  go to #29

___ Refused  go to #29

28. From oldest to youngest, what year was each child born and how many months was each child breastfed? (If a child was not breastfed, enter 0 months.)

Birth order	Birth year (yyyy)	Months breastfed	Birth order	Birth year (yyyy)	Months breastfed
1st			5th
2nd			6th
3rd			7th
4th			8th

Page 7

FISH AND SHELLFISH

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

CAUGHT FISH

Script: These questions are about the fish you eat that you caught yourself or by someone you know.

31. Compared to this model of a half-pound serving of fish, would you say that a typical meal of fish you eat is usually:

___ Less (smaller than the model)

___ Same or about the same

___ More (larger than the model)

___ Don’t know

___ Refused

32. Have you eaten fish from any of these bodies of water in New York State?

SHOW CARD AND MAPS. (Check all that apply.)

___ Lake Ontario

___ Oswego River

___ Seneca River (downstream of Lock 24 at Baldwinsville)

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

___ Don’t Know

___ Refused

Page 8 left blank

p. 9 TYPES OF FISH:  (VERY COMMON TYPES)

Alewife

White sucker

Bluegill

Brown bullhead

Carp

Gizzard shad

Golden shiner

Largemouth bass

Pumpkin-seed

Small mouth bass

Walleye

Yellow perch

Black crappie

<15”

>15”

<15”

>15”

From these bodies of water, which kinds of fish have you eaten in the last 12 months (year)?

1st ask/check types of fish eaten, then go down columns for checked types

How many times per year?

What parts of this fish (say fish type) did you usually eat?

Fillet

Skin

Cheek

Liver

Eggs/roe

Other (specify)

Don’t Know

Refused to answer

How was (say fish type) usually cleaned?

Filleted

Gutted

Trimmed fat

Trimmed belly meat

Removed cheeks

Punctured/removed skin

Did not clean

Don’t know

Refused to answer

How was (say fish type) usually cooked?

Pan fried

Deep fried

Boiled/poached

Stew/chowder

Grilled

Baked/broiled

Eaten raw

Smoked

Dried

Pickled

Don’t know

Refused to answer

p.10. TYPES OF FISH:  (COMMON TYPES)

Rock bass

Blunt- nose minnow

Bow-fin

Channel catfish

Yellow Bullhead

Brown trout

Emerald shiner

Fathead minnow

Fresh- water drum

Long- Nose gar

Shorthead Redhorse

Northern pike

Chinook Salmon

Coho Salmon

Atlantic Salmon

From these bodies of water, which kinds of fish have you eaten in the last 12 months (year)? (33b)

1ST ask/check types of fish eaten, then go down columns for checked types

How many times per year? (34b)

What parts of this fish (say fish type) did you usually eat? (35b)

Fillet

Skin

Cheek

Liver

Eggs/roe

Other (specify)

Don’t Know

Refused to answer

How was (say fish type) usually cleaned? (36b)

Filleted

Gutted

Trimmed fat

Trimmed belly meat

Removed cheeks

Punctured/removed skin

Did not clean

Don’t know

Refused to answer

How was (say fish type) usually cooked? (37b)

Pan fried

Deep fried

Boiled/poached

Stew/chowder

Grilled

Baked/broiled

Eaten raw

Smoked

Dried

Pickled

Don’t know

Refused to answer

P11. TYPES OF FISH:  (UNCOMMON TYPES)

Black bullhead

Chain pickerel

Goldfish

Greater redhorse

Green sunfish

Spotfin shiner

Lake sturgeon

Longnose dace

Northern hogsucker

Quill- back

Rainbow trout

Round goby

Rudd

From these bodies of water, which kinds of fish have you eaten in the last 12 months (year)? (33c)

1ST ask/check types of fish eaten, then go down columns for checked types

How many times per year? (34c)

What parts of this fish (say fish type) did you usually eat? (35c)

Fillet

Skin

Cheek

Liver

Eggs/roe

Other (specify)

Don’t Know

Refused to answer

How was (say fish type) usually cleaned? (36c)

Filleted

Gutted

Trimmed fat

Trimmed belly meat

Removed cheeks

Punctured/removed skin

Did not clean

Don’t know

Refused to answer

How was (say fish type) usually cooked? (37c)

Pan fried

Deep fried

Boiled/poached

Stew/chowder

Grilled

Baked/broiled

Eaten raw

Smoked

Dried

Pickled

Don’t know

Refused to answer

p. 12. TYPES OF FISH:  (UNCOMMON TYPES)

Tiger muskie

Rainbow Smelt

Lake Trout

White bass

Silver Redhorse

American eel

White Perch

Other (specify)

Other (specify)

Other (specify)

Other (specify)

Other (specify)

From these bodies of water, which kinds of fish have you eaten in the last 12 months (year)? (33d)

1ST ask/check types of fish eaten, then go down columns for checked types

How many times per year? (34d)

What parts of this fish (say fish type) did you usually eat? (35d)

Fillet

Skin

Cheek

Liver

Eggs/roe

Other (specify)

Don’t Know

Refused to answer

How was (say fish type) usually cleaned? (36d)

Filleted

Gutted

Trimmed fat

Trimmed belly meat

Removed cheeks

Punctured/removed skin

Did not clean

Don’t know

Refused to answer

How was (say fish type) usually cooked? (37d)

Pan fried

Deep fried

Boiled/poached

Stew/chowder

Grilled

Baked/broiled

Eaten raw

Smoked

Dried

Pickled

Don’t know

Refused to answer

Page 13

38. Over your lifetime, how many years have you eaten fish out of these bodies of water?

___ Years

___ Don’t know

___ Refused

39. For fish caught in any of these areas, how has the total amount of fish you eat changed during the past five years?

___ Eat less

___ Same or about the same

___ Eat more

___ Don’t know

___ Refused

WILD BIRDS AND ANIMALS

40. In the past 12 months, have you eaten waterfowl (such as ducks or geese) or bear that were hunted near any of the following bodies of water in New York State?

SHOW CARD AND MAPS.

(Check all that apply.)

___ Lake Ontario

___ Oswego River

___ Seneca River (downstream of Lock 24 at Baldwinsville)

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

___ Don’t Know

___ Refused

OTHER BEHAVIORS AND OTHER BODIES OF WATER

41. In the past 12 months, about how many times did you swim, dive, or wade (including wading for fishing or hunting) in any of these bodies of water? SHOW CARD AND MAPS.

(If never, enter 0 times.)

_____ times

___ Don’t know

___ Refused

Page 14

In the past 12 months, have you eaten fish from any of these other bodies of water in New York State? SHOW CARD

___ Finger Lake Region lakes, ponds, or rivers  Specify: ________________________

___ Skaneateles Creek

___ Erie Canal

___ Canadice Lake (Ontario County)

___ Other bodies of water in the sportfish advisories  Specify: ______________________

_______________________________________________________________________

___ Don’t know

___ Refused

STORE BOUGHT FISH

Script: The following questions are about fish bought at a store or supermarket. Please do not include fish from restaurants.

42. Which of these fish that was bought at a store or supermarket have you eaten in the past 12 months? SHOW CARD. (fill in answers by checking type of fish in table below)

Check the answer given	Grouper	Shark	Swordfish	Salmon (including canned)	Tuna (canned)	Tuna (not canned)
Ate in last 12 months (43)
None
Don’t know
Refused
If eaten, how many times in last 12 months?
None
Don’t know
Refused

44. Over your lifetime, how many years have you eaten any of these fish bought at a store or supermarket? SHOW CARD.

(If never or less than 1 year, enter 0 years.)

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

page 15

OTHER STORE BOUGHT FOODS

Script: The following questions are about typical grocery store or market foods that you may have eaten in the past 12 months. The purpose of the following four questions is to estimate if you have a high animal fat diet or low animal fat diet.

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

45. Whole eggs?

(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

46. Whole milk products (including 2% milk)?

(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

47. Poultry meat?

(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

48. Red meat?

(If never, enter 0 times per year.)

___ times per (circle one) week month year

___ Don’t know

___ Refused

Page 16

EDUCATION, OCCUPATION. AND INCOME

Script: "We also want to know about your education and occupation, and about your family's income."

49. What is the highest grade level of school or degree you have completed?

___ 8th grade or less ___ Bachelor’s degree

___ 9^th to 11^th grade, no diploma ___ Postgraduate, professional, or doctoral degree

___ High school graduate or GED ___ Don’t know

___ Some college, no diploma ___ Refused

___ Associate degree

50. Have you had a job in the past 12 months?

___ Yes go to #52

___ No  go to #54

___ Don’t know go to #54

___ Refused go to #54

Script: I would like to know what type of work you’ve done and the kind of business where you worked in the past 12 months.

51. Currently, what is your job or job title and the kind of business or organization where you work?

Job 1. __________________________ Industry 1. __________________________

(Optional) What are your usual activities or duties? __________________________

_____________________________________________________________________

52. If you had more than one job in the past 12 months, tell me about each one.

If no additional jobs, go to #19.

Job 2. __________________________ Industry 2. __________________________

(Optional) What are your usual activities or duties? ___________________________

_____________________________________________________________________

Job 3. __________________________ Industry 3. __________________________

(Optional) What are your usual activities or duties? ___________________________

_____________________________________________________________________

Job 4. __________________________ Industry 4. __________________________

(Optional) What are your usual activities or duties? ___________________________

_____________________________________________________________________

Page 17

53. Including yourself, how many family members currently live with you? Your family includes everyone currently living with you who is related to you by birth, marriage, or adoption.

_______ members

___ Don’t know

___ Refused

54. Can you tell me your total family income in {LAST CALENDAR YEAR} before taxes?

SHOW CARD.

(Check one only.)

___ Less than $15,000

___ $15,000 to less than $25,000

___ $25,000 to less than $35,000

___ $35,000 to less than $50,000

___ $50,000 to less than $75,000

___ $75,000 to less than $100,000

___ $100,000 or more

___ Don’t know

___ Refused

FISHING INFORMATION

55. Have you heard about the health advice on eating fish caught from New York State waters?

___ Yes, From who or where did you hear it? _________________________________

___ No

___ Don’t know

___ Refused

END OF INTERVIEW.