Form 0917-021017 Child Care Center Director Questionnaire

Revised
Form #
OMB #
Expires:

ENVIRONMENTAL HEALTH SURVEY OF
IHS PORTLAND AREA DIRECT SERVICE CHILD CARE CENTERS
INDIAN HEALTH SERVICE PORTLAND AREA
U.S. ENVIRONMENTAL PROTECTION AGENCY
DIRECTOR QUESTIONNAIRE

TCCC ID#:

EHO Name:

TCCC Name:

Date of Field Visit/Phone Call:

TCCC Address:

TCCC Phone:
Field Visit Time:

AM/PM

INTRODUCTION: Hello. Your child care center was selected to participate in the Environmental
Health Survey of Tribal Child Care Centers in the Pacific Northwest. I would like to ask you some
questions about this child care center to help us with this project. By participating in this project, your
facility will understand and become aware of the actual chemical and biological risks that exist in and
around your facility, while learning about specific ways to reduce those risks.  
IF RESPONDENT REFUSES TO PARTICIPATE, CONTINUE TO R1 – ELSE Q1.

REFUSE – HARD REFUSALS ONLY
I have just three quick questions so that our research team has a better understanding of the type of
center that will not be represented in our survey.
R1. Approximately how many children are enrolled?
_____________
NUMBER
DON’T KNOW
REFUSE TO ANSWER
R2. In what year was this building (or portion of the building in which your child care center is located)
built?
1986 to 2016
1978 to 1985
1960 to 1977
1946 to 1959
1940 to 1945, or
1939 or earlier
DON'T KNOW
REFUSE TO ANSWER
R3. Why did your facility decide not to participate in this survey?

Thank you very much for answering my questions today.

FACILITY
Q1. Is the center a head start facility?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q2. Who funds the program? (Circle all that apply)
TRIBE
STATE
FEDERAL
PRIVATE
DON’T KNOW
REFUSE TO ANSWER
Q3. Who owns the facility? (Circle all that apply)
TRIBE
STATE
FEDERAL
PRIVATE
DON’T KNOW
REFUSE TO ANSWER
Q4. Who owns the land? (Circle all that apply)
TRIBE
STATE
FEDERAL
PRIVATE
DON’T KNOW
REFUSE TO ANSWER
Q5. Who licenses the center? (Circle all that apply)
TRIBE
STATE
FEDERAL
PRIVATE
NOT LICENSED
DON’T KNOW
REFUSE TO ANSWER

Q6. In what year was this building (or portion of the building in which your child care center is located)
built?

1986 to 2016 (SKIP TO Q13)
1978 to 1985 (SKIP TO Q10)
1960 to 1977
1946 to 1959
1940 to 1945, or
1939 or earlier
DON'T KNOW
REFUSE TO ANSWER
Q7. Have any renovations been made to the building or facility?
YES
NO (SKIP TO Q9)
DON’T KNOW (SKIP TO Q9)
REFUSE TO ANSWER (SKIP TO Q9)
Q8. What year(s) were renovations to the center made: (Circle all that apply)
1986 to 2016
1978 to 1985
1960 to 1977
1946 to 1959
1940 to 1945, or
1939 or earlier
DON'T KNOW
REFUSE TO ANSWER
Q9. Is all renovation, painting, and repair work done since 2010 by a RRP Firm and Certified Renovator?1
YES
NO
DON’T KNOW
REFUSE TO ANSWER
NOT APPLICABLE
Q10. Has the center ever replaced their light ballasts, not just the lamps?
YES
NO
DON’T KNOW
NOT APPLICABLE
REFUSE TO ANSWER
Q11. Has your building ever replaced their windows?
YES
NO (SKIP TO Q13)
DON’T KNOW (SKIP TO Q13)

1

EPA's Lead Renovation, Repair and Painting Rule (RRP Rule) requires that firms performing renovation, repair, and
painting projects that disturb lead-based paint in homes, child care facilities and pre-schools built before 1978 have their
firm certified by EPA (or an EPA authorized state), use certified renovators who are trained by EPA-approved training
providers and follow lead-safe work practices.

REFUSE TO ANSWER (SKIP TO Q13)
Q12. When the facility replaced their windows, was the adjoining caulk also removed? (Circle all that
apply)
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q13. What is the age of the oldest fixed, outdoor playground equipment at this facility?
1986 to 2016
1978 to 1985
1960 to 1977
1946 to 1959
1940 to 1945, or
1939 or earlier
NO PLAYGROUND EQUIPMENT AT FACILITY
DON’T KNOW
REFUSE TO ANSWER
Q14. What is the main heating source in the center?
ELECTRIC-HEATED FORCED AIR (VENTS)
GAS-HEATED FORCED AIR (VENTS)
RADIATORS (STEAM OR HOT WATER)
ELECTRIC SPACE HEATER
RADIANT/CERAMIC HEATER
WOOD BURNING STOVE/FIREPLACE
KEROSENE SPACE HEATER
GAS STOVE/FIREPLACE/WALL FURNANCE
SOME OTHER SOURCE (SPECIFY _______________)
NO SOURCE OF HEAT (SKIP to Q17)
DON’T KNOW (SKIP to Q17)
REFUSE TO ANSWER (SKIP to Q17)

Q15. Are there any other sources you use for heat? (Circle all that apply)
ELECTRIC-HEATED FORCED AIR (VENTS)
GAS-HEATED FORCED AIR (VENTS)
RADIATORS (STEAM OR HOT WATER)
ELECTRIC SPACE HEATER
RADIANT/CERAMIC HEATER

WOOD BURNING STOVE/FIREPLACE
KEROSENE SPACE HEATER
GAS STOVE/FIREPLACE/WALL FURNANCE
SOME OTHER SOURCE (SPECIFY _______________)
NO OTHER SOURCES OF HEAT
DON’T KNOW
REFUSE TO ANSWER
Q16. If a wood burning stove or fireplace is used, what type of fuel is used?
CORD WOOD
PELLETS
COMPRESSED WOOD PRODUCTS/BRIQUETTES
OTHER (SPECIFY _______________)
DON’T KNOW
REFUSE TO ANSWER
NOT APPLICABLE
Q17. What is the source of drinking water for the center?2
COMMUNITY WATER SYSTEM
NON-TRANSIENT, NON-COMMUNITY WATER SYSTEM
TRANSIENT, NON-COMMUNITY WATER SYSTEM
PRIVATE WATER SYSTEM
DON’T KNOW
REFUSE TO ANSWER

SAMPLING HISTORY
Q18. Has your building ever been sampled for:
LEAD….Y N DK
PESTICIDES….Y N DK
PCBs….Y N DK
RADON….Y N DK

2

 DEFINITIONS: Community Water System (CWS): A public water system that supplies water to the same
population year-round. Non-Transient Non-Community Water System: A public water system that regularly
supplies water to at least 25 of the same people at least six months per year. Some examples are schools, factories,
office buildings, and hospitals which have their own water systems. Transient Non-Community Water System: A
public water system that provides water in a place such as a gas station or campground where people do not remain
for long periods of time. Private Water System: an unregulated water supply that serves a private residence

ENVIRONMENTAL ALLERGENS3….Y N DK
MOLD….Y N DK
VOLATILE ORGANIC COMPOUNDS (VOCs)….Y N DK
PARTICULATES…Y N DK
ASBESTOS…Y N DK
OTHER (SPECIFY _______________)
NO “YES’S” (SKIP to Q21)
REFUSE TO ANSWER (SKIP to Q21)
Q19. Were any of these contaminants detected in the sampling?
LEAD….Y N DK
PESTICIDES….Y N DK
PCBs….Y N DK
RADON….Y N DK
ENVIRONMENTAL ALLERGENS….Y N DK
MOLD….Y N DK
VOLATILE ORGANIC COMPOUNDS (VOCs)….Y N DK
PARTICULATES…Y N DK
ASBESTOS…Y N DK
OTHER (SPECIFY _______________)
NO “YES’S” (SKIP to Q21)
REFUSE TO ANSWER (SKIP to Q21)
Q20. After sampling, what recommendations were made, if any? Were you able to implement these
recommendations? If not, why?

CHILDREN SERVED
Q21. How many children are enrolled in this center?
_____________
NUMBER
DON’T KNOW
REFUSE TO ANSWER
Q22. What is the actual age range of children in this center?

3

 Includes pollen, pet dander, dust mites, molds, cockroaches, and rodents. 

a. MINIMUM
<=1 YEAR
2 YEARS
3 YEARS
4 YEARS
5 YEARS
6 YEARS
OVER 6 YEARS

b. MAXIMUM
1 YEAR
2 YEARS
3 YEARS
4 YEARS
5 YEARS
6 YEARS
OVER 6 YEARS

Q23. Would you say most of the children in this center are:
WHITE
BLACK OR AFRICAN AMERICAN
HISPANIC
ASIAN
NATIVE HAWAIIAN/ PACIFIC ISLANDER
AMERICAN INDIAN OR ALASKA NATIVE
DON’T KNOW
REFUSE TO ANSWER
Q24. What racial ethnic group is next most common?
WHITE
BLACK OR AFRICAN AMERICAN
HISPANIC
ASIAN
NATIVE HAWAIIAN/ PACIFIC ISLANDER
AMERICAN INDIAN OR ALASKA NATIVE
DON’T KNOW
REFUSE TO ANSWER
Q25. What percentage of children in the center receives a subsidy from the government to help pay for
their care (either through the family or through the center, including subsidized meals)?
NONE
LESS THAN 10%
11-20%
21-30%
31-40%
41-50%
MORE THAN 50%
DON’T KNOW
REFUSE TO ANSWER
Q26. Approximately how many enrolled children have taken medication for asthma while in the center in
the last year?
_____________
NUMBER
DON’T KNOW
REFUSE TO ANSWER
Q27. Are children required to have a blood test for lead before beginning your program?

YES
NO
DON’T KNOW
REFUSE TO ANSWER
PLAYTIME
Q28. Do you have a written hourly schedule of a typical day at your center?
YES (ASK FOR A COPY, then SKIP to Q31)
NO
DON’T KNOW
REFUSE TO ANSWER
Q29. Approximately what is the duration of free play indoor activities for a child on a typical day?4
0-29 MIN
30-59 MIN
60 or more MIN
DON’T KNOW
REFUSE TO ANSWER
OTHER (SPECIFY _______________)
Q30. Approximately what is the duration of outdoor play for a child on a typical day?
0-29 MIN
30-59 MIN
60 or more MIN
DON’T KNOW
REFUSE TO ANSWER
OTHER (SPECIFY _______________)

Q31. Does your center have a policy to check the air quality index prior to allowing outdoor activity?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
MAINTENANCE
Q32. Who performs maintenance activities and services? (Circle all that apply)
STAFF MEMBER
TRIBAL MAINTENANCE STAFF
PARENTS

4

 Free play activities are where children choose indoor classroom activities in which to participate as opposed to sedentary
activities, such as meal time, circle/story time, structured lessons, or naptime. 

CONTRACTOR
DON’T KNOW
REFUSE TO ANSWER
Q33. Is an HVAC system used?
YES
NO (SKIP TO Q36)
DON’T KNOW (SKIP TO Q36)
REFUSE TO ANSWER (SKIP TO Q36)
NOT APPLICABLE (SKIP TO Q36)
Q34. How often is your building’s HVAC system inspected?
MONTHLY
QUARTERLY
ANNUALLY
OTHER ____________
NEVER
DON’T KNOW
REFUSE TO ANSWER
NOT APPLICABLE
Q35. How often is your building’s HVAC system cleaned? (ONCE ANSWERED, SKIP to Q35)
MONTHLY
QUARTERLY
ANNUALLY
NEVER
OTHER ____________
DON’T KNOW
REFUSE TO ANSWER
NOT APPLICABLE
Q36. If an HVAC system is not used, approximately how often are windows and doors opened to allow air
exchange while the building is open?
NEVER
ONLY WHEN WE HAVE AN ODOR PROBLEM
10% OF THE TIME THE BUILDING IS OCCUPIED
25% OF THE TIME THE BUILDING IS OCCUPIED
50% OF THE TIME THE BUILDING IS OCCUPIED
75% OF THE TIME THE BUILDING IS OCCUPIED
DON’T KNOW
REFUSE TO ANSWER
CLEANING
Q37. Who performs cleaning and other custodial activities and services? (Circle all that apply)
STAFF MEMBER
TRIBAL STAFF

PARENTS
CONTRACTOR
DON’T KNOW
REFUSE TO ANSWER
Q38. How often are the center’s elevated surfaces and hard floors cleaned?
DAILY
2-3 TIMES/WEEK
WEEKLY
MONTHLY
NEVER
OTHER ____________
DON’T KNOW
REFUSE TO ANSWER

Q39. How often are the center’s carpeted floors vacuumed?
DAILY
2-3 TIMES/WEEK
WEEKLY
MONTHLY
NEVER (SKIP TO Q41)
OTHER ____________
NO CARPETING
DON’T KNOW
REFUSE TO ANSWER

Q40. Is the vacuum equipped with a high efficiency particulate air (HEPA) filter? 
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q41. How often are children’s toys washed?
DAILY
2-3 TIMES/WEEK
WEEKLY
MONTHLY
NEVER (SKIP TO Q43)
OTHER ____________
DON’T KNOW
REFUSE TO ANSWER
Q42. How does the center wash children’s toys? (Circle all that apply)

SOAP AND WATER
VINEGAR AND WATER
DISINFECTANT
COMMERCIAL WASHER & DRYER
OTHER____________
DON’T KNOW
REFUSE TO ANSWER
Q43. Where in the center is a disinfectant used on a regularly scheduled basis? (Circle all that apply)
KITCHEN
BATHROOM
PLAY AREA
EATING AREA
OTHER ____________
DON’T KNOW
REFUSE TO ANSWER
Q44. Does the center have a hand washing policy?
YES
NO
DON’T KNOW
REFUSE TO ANSWER

AIR QUALITY
Q45. Does the center use air fresheners (includes sprays, plug-ins, wickless candles) or scented or
unscented candles?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q46. Does the center have a policy against cars or other vehicles idling in the parking lots?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q47. Does the center have a smoking policy?
YES
NO
DON’T KNOW

REFUSE TO ANSWER
Q48. In the past 12 months have there been any ambient air quality alerts or burn bans in the area?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
MOISTURE/MOLD
Q49. During the past 12 months, has there been water or dampness in the center from broken pipes,
leaks, heavy rain, or floods?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
Q50. During the past 12 months, has the center had visible mold?
YES
NO
DON’T KNOW
REFUSE TO ANSWER

Q51. During the past 12 months, has a dehumidifier been used in the center?
YES
NO
DON’T KNOW
REFUSE TO ANSWER
PESTS
Q52. Have you ever had any problems with cockroaches in the center?
YES
NO (SKIP TO Q54)
DON’T KNOW (SKIP TO Q54)
REFUSE TO ANSWER (SKIP TO Q54)
Q53. If so, when?
CURRENTLY
WITHIN THE PAST YEAR
1-3 YEARS AGO
MORE THAN 3 YEARS AGO
DON’T KNOW
REFUSE TO ANSWER

Q54. Have you ever had any problems with rodents in the center?
YES
NO (SKIP TO Q56)
DON’T KNOW (SKIP TO Q56)
REFUSE TO ANSWER (SKIP TO Q56)
Q55. If so, when?
CURRENTLY
WITHIN THE PAST YEAR
1-3 YEARS AGO
MORE THAN 3 YEARS AGO
DON’T KNOW
REFUSE TO ANSWER
Q56. Have you ever had had any problems with stinging or biting insects in or around the center?
YES
NO (SKIP TO Q58)
DON’T KNOW (SKIP TO Q58)
REFUSE TO ANSWER (SKIP TO Q58)

Q57. If so, when?
CURRENTLY
WITHIN THE PAST YEAR
1-3 YEARS AGO
MORE THAN 3 YEARS AGO
DON’T KNOW
REFUSE TO ANSWER
PESTICIDE USE
Q58. For all pesticide sprays, when are pesticides applied? (Circle all that apply)
DURING OPERATING HOURS
OUTSIDE OF OPERATING HOURS
SPRAYING DOES NOT OCCUR
DON’T KNOW
REFUSE TO ANSWER
Q59. In the past 12 months, what was the intent for pesticides being used in or around your facility?
(Circle all that apply)
TO PREVENT A PEST PROBLEM FROM OCCURING
TO CONTROL AN EXISTING ISSUE
PESTICIDES HAVE NOT BEEN APPLIED IN THE PAST 12 MONTHS (SKIP TO END)

The following set of questions pertains to indoor pesticide applications. 
Q60. In the past 12 months, have any insecticides, bug sprays, bug bombs, roach motels, or baits been
used to control for ants, cockroaches, crickets, spiders, silverfish, termites, or other insects inside the
center?
YES
NO (SKIP TO Q62)
DON’T KNOW (SKIP TO Q62)
REFUSE TO ANSWER (SKIP TO Q62)
Q61. Who applied the insecticides, bug sprays or baits inside the center? (Circle all that apply)
CENTER STAFF Licensed? Y/N
TRIBAL STAFF Licensed? Y/N
PROFESSIONAL PEST CONTROL
OTHER ___________
DON’T KNOW
REFUSE TO ANSWER

Q62. In the past 12 months, have any rodenticides been used inside to control rodents?
YES
NO (SKIP TO Q64)
DON’T KNOW (SKIP TO Q64)
REFUSE TO ANSWER (SKIP TO Q64)
Q63. Who applied the rodenticides inside the center? (Circle all that apply)
CENTER STAFF Licensed? Y/N
TRIBAL STAFF Licensed? Y/N
PROFESSIONAL PEST CONTROL
OTHER ___________
DON’T KNOW
REFUSE TO ANSWER
Q64. Do you have records of all pesticide applications applied indoors in the past 12 months that we may
have?
YES (Request a copy of any pesticide work orders or contract for services. These will usually list
the NAME AND PHONE NUMBER OF THE APPLICATOR, specific pesticides applied and when,
and may list where pesticides were applied. At least, ask them to look for a phone number. THEN
SKIP TO Q66)
PARTIAL RECORDS
NO
DON’T KNOW
NO PESTICIDES HAVE BEEN APPLIED INDOORS (SKIP TO Q68)
REFUSE TO ANSWER

Q65. For all pesticides applied indoors during the past 12 months, please answer the following to the
best of your ability (If an answer is NOT KNOWN, enter DK):
a. What
pesticides
were used
indoors?

P1. Pesticide 1

P2. Pesticide 2

P3. Pesticide 3

P4. Pesticide 4

b. What was
its
formulation?
(Circle one
of the
following)

c.

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Where
was it
applied?
(Circle all
that
apply)

d. How often
was it
applied?
(Circle one
of the
following)

e. When did
the staffer
last use the
pesticide?
(MM/YR)

f.

What
pest(s)
was
being
targeted?
(Writeout)

g. Who
applied
the
product?
(Circle
one of
the
following)
Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other

Don’t Know
Refuse to
Answer

P5. Pesticide 5

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Q66. For indoor pesticide applications applied by a pest management professional in the past 12
months, may we have permission to call the company(s) to receive or verify the name of the pesticide(s)
used?
YES
NO (SKIP TO Q69)
DON’T KNOW (SKIP TO Q69)
NOT APPLICABLE (SKIP TO Q69)
REFUSE TO ANSWER (SKIP TO Q69)
Q67. What is the name of the company(s) that applied pesticides indoors?
____________________________________________________________________________
Q68. Would the name of the account be something other than (TCCC NAME)?
YES
IF YES, ACCOUNT NAME__________________
NO
DON’T KNOW
REFUSE TO ANSWER
The following set of questions pertains to outdoor pesticide applications:
Q69. In the past 12 months, have any insecticides, bug sprays, or baits been used outdoors to control for
ants, crickets, roaches, spiders, silverfish, termites, or other outdoor insects?
YES
NO (SKIP TO Q71)
DON’T KNOW (SKIP TO Q71)
REFUSE TO ANSWER (SKIP TO Q71)
Q70. Who applied the insecticides, bug sprays, or baits outdoors? (Circle all that apply)
CENTER STAFF Licensed? Y/N

TRIBAL STAFF Licensed? Y/N
PROFESSIONAL PEST CONTROL
OTHER ___________
DON’T KNOW
REFUSE TO ANSWER
Q71. In the past 12 months, have any rodenticides been used outdoors to control rodents?
YES
NO (SKIP TO Q73)
DON’T KNOW (SKIP TO Q73)
REFUSE TO ANSWER (SKIP TO Q73)

Q72. Who applied the rodenticides outdoors? (Circle all that apply)
CENTER STAFF Licensed? Y/N
TRIBAL STAFF Licensed? Y/N
PROFESSIONAL PEST CONTROL
OTHER ___________
DON’T KNOW
REFUSE TO ANSWER
Q73. In the past 12 months, have any herbicides been used outdoors to control weeds?
YES
NO (SKIP TO Q75)
DON’T KNOW (SKIP TO Q75)
REFUSE TO ANSWER (SKIP TO Q75)
Q74. Who applied the herbicide outdoors? (Circle all that apply)
CENTER STAFF Licensed? Y/N
TRIBAL STAFF Licensed? Y/N
PROFESSIONAL PEST CONTROL
OTHER ___________
DON’T KNOW
REFUSE TO ANSWER
Q75. Do you have records of all pesticide applications applied outdoors in the past year that we may
have?
YES (Request a copy of any pesticide work orders or contract for services. These will usually list
the NAME AND PHONE NUMBER OF THE APPLICATOR, specific pesticides applied and when,
and may list where pesticides were applied. At least, ask them to look for a phone number. THEN
SKIP TO Q77)
PARTIAL RECORDS
NO
DON’T KNOW
NO PESTICIDES HAVE BEEN APPLIED OUTDOORS (SKIP TO END)
REFUSE TO ANSWER

Q76. For all pesticides applied outdoors during the past 12 months, please complete the following to the
best of your ability (if an answer is NOT KNOWN, enter DK):

a. What
pesticides
were used
outdoors?

P1. Pesticide
1

P2. Pesticide
2

P3. Pesticide
3

b. What was its
formulation?
(Circle one
of the
following)

c.

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Where
was it
applied?
(Circle
all that
apply)

d. How often
was it
applied?
(Circle
one of the
following)

e. When did
the staffer
last use
the
pesticide?
(MM/YR)

f.

What
pest(s)
was being
targeted?
(Writeout)

g. Who
applied
the
product?
(Circle
one of the
following)
Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Perimeter
Turf (Spot)
Turf
(Broadcast)
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Perimeter
Turf (Spot)
Turf
(Broadcast)
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Perimeter
Turf (Spot)
Turf
(Broadcast)
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control

Other
Don’t Know
Refuse to
Answer

P4. Pesticide
4

P5. Pesticide
5

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Perimeter
Turf (Spot)
Turf
(Broadcast)
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Perimeter
Turf (Spot)
Turf
(Broadcast)
Other?
DK

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Center Staff
Licensed?
Y/N
Tribal Staff
Licensed?
Y/N
Professional
Pest Control
Other
Don’t Know
Refuse to
Answer

Q77. For outdoor pesticide applications applied by a pest management professional, may we have
permission to call the company(s) to receive or verify the name of the pesticide(s) used?
YES
NO (SKIP TO END)
DON’T KNOW (SKIP TO END)
REFUSE TO ANSWER (SKIP TO END)
NOT APPLICABLE (SKIP TO END)
Q78. What is the name of the company(s) that applied pesticides outdoors?
________________________________________________________________________________
Q79. Would the name of the account be something other than (TCCC NAME)?
YES
IF YES, ACCOUNT NAME__________________
NO
DON’T KNOW
REFUSE TO ANSWER
END- Thank you very much for taking the time to answer my questions today.