Iola KS Exposure Investigation Questionnaire

Form Approved

OMB No. 0923-0048

Exp. Date 03/31/2019

Attachment 4: BLL in Iola KS Questionnaire

Iola KS Exposure Investigation Questionnaire

Introduction - Hello my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention (CDC). As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions on your contact with lead. We are asking these questions to better understand all the data we collect.

The questions should take about 20 minutes. After that, we will be offering free blood testing for participants in this exposure investigation. Once we are done with this investigation, you will be given a copy and details of the testing results for you and your children (if you have them). Generally, we are able to get results to you within 12 weeks.

Cost Recovery Number: 7A8Q

1. Person Administering Questionnaire­­­­­­­­­­­­­­­­­­­­­­_______________________________________

2. Date Questionnaire Administered_________________________________________

3. Participant last name___________________________________________________

4. Participants first name__________________________________________________

5. Address:_____________________________________________________________

6. Mailing address if different from home address: _____________________________

7. Laboratory ID________________________________________________________

ATSDR estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0923-0048).

Now I want to ask you questions about how I can contact you. I will also be asking how long you have lived at or visited certain places. This is needed to find out how long you may have had contact with lead and how long it may have lasted. We will also ask your age, address, race, and about how you spend your time (e.g, child at daycare, how often they play outside, your jobs and hobbies). This is useful to help us better understand your test results.

8. Is the person being interviewed a minor (if NO, skip to question 21)?

Yes No

9. Name of person answering questions for minor child:

10. Relationship to child:

Mother

Father

Grandparent

Guardian

11. Has your child ever had their blood tested for lead (if NO, skip to question 13)?

12. If yes, when, where and what was the result?

13. Does your child go to daycare or school during the day (if NO, skip to question 15)?

14. If yes, how long is your child out of the house during the day and how many times per week do they go?

15. How many hours per day does your child typically play in your yard?

16. Does your child wash their hands before eating?

Always

Sometimes

Never

17. Does the child put their hands or toys in their mouth (if NO, skip to question 19)?

18. If yes, what and how often?

19. Have you noticed the child eating dirt while playing outside (if NO, skip to question 21)?

20. If yes, how often?

21. How long have you lived at this address?

Less than 6 months

6 months to less than 2 years

2 to 5 years

6 to 10 years

More than 10 years

22. How long have you lived in Iola, KS?

Less than 6 months

6 months to less than 2 years

2 to 5 years

6 to 10 years

More than 10 years

23. How often do you clean your home (e.g., sweep, mop)?

Daily

Several times a week

Weekly

Monthly

Other

24. Do you speak a language other than English at home? [If NO, skip to next section]

Yes No

25. If you speak another language in the household do you prefer receiving follow up information in another language? What is this language?

Demographic Questions - Script: The next questions are about qualities of the person who is being tested (you or your child/ward) your or your child’s qualities own qualities and will help us better understand your test results.

26. What is your or your child/ward’s sex?

Male

Female

27. What is your or your child/ward’s date of birth?

28. Are you or your child/ward Hispanic, Latino/a, or Spanish Origin? (one or more categories may be selected)

No, not of Hispanic Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, Other Hispanic, Latino, or Spanish Origin

29. What is your or your child/ward’s race? (one or more categories may be selected)

White

Black or African American

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Participant declined to answer

30. Are you pregnant? If yes in what month of pregnancy?

Don't know

No

Yes, 0 to 3 months

Yes, 4 to 6 months

Yes, 7 to 9 months

31. How much time do you or your child/ward spend outdoors in a typical day?

Never go outside

Less than 1 hour

1 to 3 hours

More than 3 hours

Attributes of the Structure or Home - The following questions are about the qualities and characteristics of your home.

31. Do you live in a(n):

Apartment

Single Family Home

Townhouse or Condominium

Mobile Home

Other

31. About when was the building built?

2000—present

1990—1999

1980—1989

1970—1979

1960—1969

1950—1959

1940—1949

1939 or earlier

Don’t know

31. What is the condition of your home or building?

Good

Fair

Poor

31. Do the windows (e.g., sills) have peeling paint?

Yes No

31. Is there peeling paint in other places such as cabinets, interior walls and/or exterior walls?

Yes No Don’t know

Soil Information (Tracking inside home)

36. Does your home have a yard with grass/dirt?

37. How often do you or your child/ward remove shoes before entering your home?

Never do this

Seldom do this

Sometimes do this

Always do this

36. Does anyone in the home work primarily outdoors in a job with frequent soil contact? (construction worker, landscaping, etc.) (if NO, skip to question 39)

Yes No Don’t know

36. How often do they change clothing when entering the home after work outdoors?

Never do this

Seldom do this

Sometimes do this

Always do this

36. Have you used any Mexican pottery in the past month?

Yes No Don’t know

36. Have you used any home remedies in the past month for any illnesses?

Yes No Don’t know

36. Have you eaten any Mexican candy in the past month?

Yes No Don’t know

44. Is there anything you want us to know about you or your child that we did not ask about?