Household Inventory

Appendix D4 (Household inventory)

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-15AFJ

Exp. Date xx/xx/20xx

Household ID#

Date

Interviewer's Initials

Public reporting burden of this collection of information is estimated to average 10 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-XXXX).

*Note to Field technician: If this is the first time administering this questionnaire to the participant, ask all questions, otherwise, ask the gateway question before each question.

A. Household Cleaning Products (To be completed by field technician and participant)

Gateway question for #1: Did the type or frequency of use of cleaning products change from the last time we visited your home? Yes No Don’t know

If YES, then ask #1

1. Please select use frequency for each product type inside your home

	Daily	Weekly	Monthly	Yearly/Never
All-purpose cleaner
Glass cleaner
Floor cleaner
Toilet bowl cleaner
Carpet cleaner
Polish or wax
Air freshener
Disinfectant Spray
Laundry detergent
Dryer sheets
Stain/spot remover

B. Personal Care Products (To be completed by field technician and participant)

Gateway question for #2: Did the type or frequency of use of personal care products change from the last time we visited your home? Yes No Don’t know

If YES, then ask #2

2. Please select use frequency for each product type inside your home

	Daily	Weekly	Monthly	Yearly/Never
Shampoo
Liquid hand soap
Hand sanitizer
Hand/body lotion
Facial moisturizer
Fragrance/perfume
Hair styling products
Sunscreen

C. Consumer Product Classes (To be completed by field technician and participant)

Gateway question for #3: Did the type or frequency of use of any of these products change from the last time we visited your home? Yes No Don’t know

If YES, then ask #3

3. Please select use frequency for each product type inside/near your home

	Daily	Weekly	Monthly	Yearly/Never
Arts and Crafts Products
Automotive Products
Home Maintenance
Cleaning Products
Personal Care Products
Pesticides
Pet Care Products
Home Office
Landscape and Yard

D. Home Observations (To be completed by field technician with input from participant as needed)

Gateway question for #4a and #4b: Did the type of floor covering change from the last time we visited your home? Yes No Don’t know

If YES, then ask #4a and #4b

4a. Select the answer(s) that best describe the percentage of total floor area in the home.

	0	1-20	21-40	41-60	61-80	81-100
% Covered by carpet or rug
% Exposed linoleum or linoleum tile
% Exposed wood or wood laminate
% Exposed ceramic or stone tile
% Exposed other

4b. If a percentage of the floor was "Other," what was the material?

Gateway question for #5a & #5b: Did the type or number of furniture pieces change from the last time we visited your home? Yes No Don’t know

If YES, then ask #5a & #5b

5a. Select the answer(s) that best describe the home's furniture.

	0	1	2	3	4	5 or more
Number of upholstered sofas
Number of upholstered chairs
Number of other upholstered furniture
Number of twin beds w mattresses
Number of double beds w mattresses
Number of queen beds w mattresses
Number of king beds w mattresses

5b. Select the answer(s) that best describe the percentage of upholstery material for the home’s furniture.

	0	1-20	21-40	41-60	61-80	81-100
% Fabric covering
% Vinyl covering
% Leather covering
% Other