Hayden, Arizona Smelter Exposure Investigation Questiona

Form approved
0923­0048
Exp Date
03/31/2019

Hayden, Arizona Smelter Exposure Investigation Questionaire
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. 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 chemicals. We are asking these questions to better
understand all the data we collect.
The questions should take about 25 minutes. After that, we will be offering free urine testing for participants in
this exposure investigation. Once we are done with this investigation, you will be given a copy and details of your 
and your’s children (if you have them) test results. Generally, we are able to get results to you within 12 weeks.

1. Person administraiting questionaire

2. Date Questionaire Administered
mm/dd/yyyy
3. Participant last name

4. Participants first name

5. Middle initial

6. Laboratory ID

ATSDR estimates the average public reporting burden for this collection of information as 25 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 (0923­0048).

Now I want to ask you questions about how can I 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 chemicals and how
long it may have lasted. We will also ask your age, race, weight and height and about your jobs. This is useful to
put your test results side by side with others like you to see what is typical.
7. Is the person being interviewed a minor?
Yes
No

8. Name of person answering questions for minor child

9. Residential street address

10. Additional Street Address information (Apt. Number, Other defining number)

11. City

Hayden
Winkelman
12. County
Gila
Pinal
13. State
AZ
14. Zip Code

15. Is the mailing address different from your street address? If so, what is your mailing address?
Yes
No
16. Alternate mailing address

17. City
Hayden
Winkelman
18. County
Gila
Pinal
19. State
AZ
20. Zip Code

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 Hayden or Winkelmen, AZ?
Less than 6 months
6 months to less than 2 years
2 to 5 years
6 to 10 years
More than 10 years

23. Do you speak a language other than English at home? (5 years old and older) [If NO skip the next
question]

Yes
No
24. If you speak another language in the household do you prefer receiving follow up information in another
language? What is this language? (5 years old and older)
Yes, Spanish
No, Other

Demographic Questions ­ Script: The next questions are about your own qualities and will
help us compare your test results. Surveyor, please indicate whether the person is a male or
female. If this questionaire is for a minor child, be sure to ask their gender.
25. What is your sex?
Male
Female
26. What is your date of birth?

27. Are you Hispanic or Latino?
Hispanic or Latino
Not Hispanic or Latino

28. What is your race? (one or more categories may be selected)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

29. (If female between 15­44) 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
30. How much time do you spend outdoors in a typical day?
Never go outside
Less than 1 hour
1 to 3 hours
More than 3 hours
31. Have you been to areas with mine waste/tailings in the past 30 days?

Yes
No
Don’t know

Attributes of the Structure or Home ­ The following questions are about the qualities and
characteristics of your home.
32. Do you live in an:
Apartment
Single Family Home
Townhouse or Condominium
Mobile Home
Other
33. About when was the building built?
2000 to present
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
Dont know
34. What is the condition of your home or building?
Good
Fair
Poor

Soil Information (Tracking inside home)
35. How often do you 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 in the smelter?
Yes
No
Don’t Know
37. How often do they change clothing when entering the home after work at the smelter?
Never do this
Seldom do this
Sometimes do this
Always do this
38. Does anyone in the home work primarily outdoors in a job with frequent soil contact? (construction,
landscaping, etc.)
Yes
No
Don’t Know
39. 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

Food
40. Have you eaten dirt?
Yes, frequently
Yes, not frequently
No
Dont know
41. Do you put dirty fingers and/or toys in your mouth?
Yes, frequently
Yes, not frequently
No
Dont know
42. How many portions of rice (white or brown) did you eat in the past week?
None
1 to 2
3 to 4
5 or more
Dont know
43. How many portions of chicken did you eat in the past week?
None
2 to 2
4 to 4
5 or more
Dont know
44. How many portions of fish and other seafood (to include shrimp) did you eat in the past week?
None
3 to 2
5 to 4
5 or more
Dont know

Other
45. Is there anything you want us to know that we did not ask about?