Form 11 Attachment 21 Dust Questionnaire

Attachment 21: Dust Collection Questionnaire:

OMB #: 0925-0406
Expiration date: 09/30/2016

THE STUDY OF BIOMARKERS OF EXPOSURES
AND EFFECTS IN AGRICULTURE
Dust Collection Questionnaire

_______________– DT02

If you own a vacuum cleaner, and if you agree, we would like to collect the dust from your machine. Between now and your visit,
you may use your vacuum cleaner as you normally would, but we ask that you not empty it or change bags if possible. If you do need
to change bags or empty the vacuum canister, we ask that you try to use the vacuum at least once with the new bag or empty
canister before your visit, so there is dust available in the machine. When we come to your home, we will ask to see the machine
and will either remove the used bag or empty the dust from the machine or bag. If you have more than one vacuum machine, we
would like to obtain the dust sample from the vacuum you use most frequently in your home. If the machine you use most often is a
hand-held vacuum or shop vac, and you also own a standard vacuum cleaner, we would like to obtain the dust sample from the
standard vacuum.
We have prepared this brief questionnaire to ask for information about your vacuum cleaner, recent use, and the areas in your
home where you may have vacuumed. If there are others in your household that can help you with answering these questions,
please feel free to share the questionnaire with them. We will collect and review your questionnaire during the home visit. Please
call us at 1-800-xxx-xxxx if you have any questions.

Instructions
 Please use a black or blue pen to complete this form. Do not use a felt-tip pen or a pencil.
 Mark  to indicate your answer.
 If you want to change your answer, mark through the box on the wrong answer , and mark the correct
answer.
 Your answers are important. Please print clearly using uppercase, block letters (for example, “WEDNESDAY”).
Today’s Date: |___|___| / |___|___| / |___|___|
M

M

D

D

Y

Y

1. Type of vacuum:

 Standard vacuum (with a disposable bag)
 Bagless vacuum
 Handheld vacuum (with a disposable bag)
 Handheld vacuum (without a bag or with a
reusable cloth bag)

 Central house collection system
 Robotic vacuum
 Hard surface vacuum (with a disposable bag)
 Hard surface (without a bag or with a reusable

2. Make and model of vacuum:
For example:
Make: Hoover
Model#: Windtunnel Rewind H09A
Make: _______________________________
Model#: _____________________________

cloth bag)

 Shop vac
 Other, specify____________________

Public reporting for this collection of information is estimated to average ten 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: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406). Do not return the completed form to this address.

3. Approximately, how long has it been since the
vacuum was last used? Enter the number and select
the time period from the choices below.
|___|___|

 Days
 Weeks

 Months
 Years

 Refused
 Don’t know

4. Have you changed your vacuum bag or emptied the
dust from your vacuum since it was last used?

 Yes

 No

5. Approximately, how long has it been since you
changed your vacuum bag or emptied the dust from
your vacuum cleaner? Enter the number and select
the time period from the choices below.
|___|___|

 Days
 Weeks

 Months
 Years

 Refused
 Don’t know

6. Since the vacuum bag was changed or since you
emptied the dust from your vacuum, has your
vacuum been used in a place other than inside your
home, such as. . .?
MARK ALL THAT APPLY

 Your car
 Your garage
 Your porch
 Someone else’s home
 Central house collection system
 A hallway outside your apartment
 Other, specify____________________
 Not applicable, vacuum only used in home
7. Approximately, how many rooms are usually
vacuumed with this vacuum cleaner?

9. Approximately when did you most recently replace
any carpets or rugs in the room(s) where you use
this vacuum?

 Less than 6 months ago
 Between 6 months and 1 year ago
 Between 1 and 5 years ago
 More than 5 years ago
10. Approximately when was this home built?

 Before 1940
 Between 1940 and 1969
 Between 1970 and 1989
 Between 1990 and 2009
 After 2009
11. Do you have air conditioning in your home?

 Yes

 No

If yes, do you have central air or another system,
such as a window unit?

 Central Air
 Other system, such as a window unit
12. Would you say that you and other members of your
household remove your shoes before entering the
house. . .?

 Always or almost always
 Sometimes
 Almost never or never
13. Would you say that you and other members of your
household remove your work shoes or boots before
entering the house. . .?

 Always or almost always
 Sometimes
 Almost never or never

|___|___|
8. Approximately, how many rooms that are vacuumed
have carpets or rugs?
|___|___|

Thank you very much for completing this questionnaire. All of your answers are very important.
For safekeeping,
v. 03/7/13

please store your completed questionnaire with the other documentation from your pre-visit
package until the day of home visit.