Draft - Introductory Survey Sample

Att 5 - Introductory Survey.doc

Lyme and other Tickborne Diseases Knowledge, Attitude, and Practice Surveys

Draft - Introductory Survey Sample

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Attachment 5

Lyme & Other Tickborne Diseases Prevention Study

Knowledge, Attitudes, and Practices

Introductory Survey



Interview Date:

Interviewer’s Initials:

Household ID #:


HOUSEHOLD INFORMATION


The next step in this study will be to take a short introductory survey about your yard, your recreational activities in your yard, and ticks. We will ask your permission to complete the introductory survey questions now. This survey should take no more than 10 minutes to complete. You will not receive a direct benefit from being part of this survey. Helping to carry out this research has a chance to tell us a lot about how to prevent tickborne diseases. This could be of future benefit to you or someone you know. There are no costs for participating in this survey. As compensation for your time and effort, you will receive a $X gift card in the mail along with the study forms.


Before we begin I would like to remind you that participation in this survey is voluntary and you may refuse to answer any questions and may stop at any time. I would like to begin by asking some general questions about you.


  1. How long has your family lived at this address? _________ Years _________ Months


  1. Last summer, did you find any ticks crawling on or attached to you after spending time in your yard?



(1) Yes (2) No (3) Not applicable (didn’t live there last year)

(4) Don’t know/Not sure

(5) Refused

  1. I would now like to ask you about the members of your household. Who lives in your home?




Family ID

(LTDPS #-Family #)



Relationship to interviewee and initials

(must include self)



Date of

birth

(mm/dd/yyyy)




Sex

Have/has [you or a household member] ever been diagnosed by a physician as having Lyme disease, babesiosis, anaplasmosis or ehrlichiosis? Any other tickborne disease?


When was the most recent onset of [Disease]?

(month/year)


Are [you/he/she] currently being treated for this illness?

a.

Self (Initials)


M F

No



Yes, Lyme disease


Yes No

Yes, Babesiosis


Yes No

Yes, Anaplasmosis/Ehrlichiosis


Yes No

Other, please specify

_______________________


Yes No

Don’t know/Not sure



Refused



b.

Etc.


M F

No



Yes, Lyme disease


Yes No

Yes, Babesiosis


Yes No

Yes, Anaplasmosis/Ehrlichiosis


Yes No

Other, please specify

_______________________


Yes No

Don’t know/Not sure



Refused



c.

Etc.


M F

No



Yes, Lyme disease


Yes No

Yes, Babesiosis


Yes No

Yes, Anaplasmosis/Ehrlichiosis


Yes No

Other, please specify

_______________________


Yes No

Don’t know/Not sure



Refused




GENERAL PROPERTY CHARACTERISTICS


Now I would like to ask you some questions about your house and property.

  1. Do you live in a home or housing development that was built more than 10 years ago?

Yes

No

Don’t know/Not sure

Refused

  1. What is the size of the lot on which your current home is located?

1 acre or less

> 1 acre but less than 2 acres

2-2.9 acres

3-3.9 acres

4 acres or more

Don’t know/Not sure

Refused

  1. How much of your property is composed of woods or forested areas?

None of it

Less than half of it

About half of it

Greater than half of it

All of it

Don’t Know/Not Sure

Refused

  1. How much of your property is lawn? [Lawn is a maintained grassy area]

No lawn on property

Less than half of it

About half of it

Greater than half of it

All of it

Don’t Know/Not Sure

Refused

  1. Does your property include woody or brushy areas?

Yes

No

Don’t know/Not sure

Refused


LANDSCAPE CHARACTERISTICS


  1. On average, how frequently is your lawn mowed during the spring and summer months? [Between the months of May and September]

Less than once per month

Once to three times per month

Weekly

More often than weekly

Don’t Know/Not Sure

Refused

  1. Who mows your lawn?

Household member

Non-household member

Professional lawn care service

Other [specify] ____________________

Don’t Know/Not Sure

Refused

  1. Do you have a vegetable garden in your yard?

Yes

No

Don’t Know/Not Sure

Refused

  1. Do you have a flower garden in your yard?

Yes

No

Don’t Know/Not Sure

Refused

  1. Do you have a compost pile?

Yes

No

Don’t Know/Not Sure

Refused

  1. Do you have a log pile in your yard?

Yes

No

Don’t Know/Not Sure

Refused

  1. Do you have a bird feeder in your yard for seed-eating birds?

Yes

No

Don’t Know/Not Sure

Refused

  1. Does your yard have fencing around it or parts of it?

Yes

No

Don’t Know/Not Sure

Refused

  1. Do you have one or more stone walls, not sealed by mortar or cement, in your yard or adjacent property line?

Yes

No

Don’t Know/Not Sure

Refused

  1. What type of recreational areas do you have in your yard that are not located on a deck or patio?


    1. Children’s recreational equipment (e.g. jungle gym, swing set, sandbox, etc.)?

Yes

No

Don’t Know/Not Sure

Refused

    1. Dining area (e.g. picnic table, etc.)?

Yes

No

Don’t Know/Not Sure

Refused

    1. Sitting area (e.g. bench, hammock, etc.)?

Yes

No

Don’t Know/Not Sure

Refused

    1. Lawn sport area (e.g. horseshoe pit, volleyball, badminton, bocce, etc.)?

Yes

No

Don’t Know/Not Sure

Refused

    1. Other?




PERSONAL PROTECTION


I would like to ask you some questions about time spent in your yard and outdoors during the spring and summer months. For the purpose of this study, your yard is defined as all of the land on your property, not including your house, driveway, deck, porch, patio, garage, or other buildings on the property. For example, your yard may include a lawn, woods, and a garden.

  1. Approximately how many hours per week do you spend in your yard?


< 1 hour

1 – 5 hours

6 – 10 hours

>10 hours

Don’t know/Not sure

Refused

  1. When spending time in your yard, where do you spend most of your time?

Outdoor dining area

(i.e., non-grassy area: patio/deck)

Lawn

Woody or brushy areas

Other

  1. Approximately how many hours per week do you spend doing outdoor activities not on your property?

< 1 hour

1 – 5 hours

6 – 10 hours

>10 hours

Don’t know/Not sure

Refused

  1. In the last year, have any of your family members found ticks on their bodies?

Yes (If yes to Q2 or Q22, go to Q23)

No (Go to Q24)

Don’t know/Not sure (Go to Q24)

Refused (Go to Q24)

  1. Overall, how many tick bites did you and each of your family members have last year? (household total)

__________________

Don’t know/Not sure

Refused

  1. How often do you use insect repellent when spending time in your own yard?

All the time

More than half the time

About half the time

Less than half the time

Never

Don’t know/Not sure

Refused

  1. How often do you use insect repellent when spending time outside of your yard?

All the time

More than half the time

About half the time

Less than half the time

Never

Don’t know/Not sure

Refused

  1. Does your insect repellent contain DEET?

Yes

No

Don’t know/Not sure

Refused

My family does not use insect repellent

  1. Does your insect repellent contain picaridin?

Yes

No

Don’t know/Not sure

Refused

My family does not use insect repellent

  1. Does your insect repellent contain IR3535?

Yes

No

Don’t know/Not sure

Refused

My family does not use insect repellent


PETS


  1. Do you have house pets that spend time both indoors and outside in your yard?

Yes

No (if no pets, skip to ‘other’)

Don’t Know/Not Sure

Refused


  1. Do you have a dog?

Yes

No

Don’t know/Not sure

Refused

  1. If yes, do you use tick control on your dog?

Yes

No

Don’t know/Not sure

Refused

  1. Do you have a cat?

Yes

No

Don’t know/Not sure

Refused

  1. If yes, do you use tick control on your cat?

Yes

No

Don’t know/Not sure

Refused


OTHER


  1. What is the highest grade or year of school you completed?

Never attended school or kindergarten

Elementary or middle school; 1st – 8th grade

Some high school; 9th – 11th grade

High school graduate; 12th grade or GED

College or technical school for 1-3 years

College for 4 years, with or without a degree

Graduate school

Don’t know/Not sure

Refused

  1. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

Don’t know/Not sure

Refused

  1. What is your race? (check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other, please specify____________________

Don’t know/Not sure

Refused

  1. In your home, what is the annual household income from all sources, including social security and pensions? (read ranges)

less than $15,000

less than $25,000

less than $35,000

less than $50,000

less than $70,000

$70,000 or more

Don’t know/Not sure

Refused

  1. How did you learn about the study?



  1. Could you please provide/confirm your home address?



  1. Do you have pets that go outdoors?



  1. What is your preferred method of contact and the best day/time to reach you?





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File Typeapplication/msword
AuthorKay, Ashley B. (CDC/OID/NCEZID)
Last Modified BySamuel, Lee (CDC/OID/NCEZID)
File Modified2016-06-01
File Created2016-05-24

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