Form 0917-021017-1 Pesticide Applicator 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
PESTICIDE APPLICATOR QUESTIONNAIRE
[Complete one questionnaire for each pesticide applicator listed by the center.]
TCCC ID#:

Applicator Company Name:

TCCC Name/ Account name for
pesticide application:

TCCC Reported Professional Application:
1- Indoors

TCCC Phone:
TCCC Address:

Init

Date

2- Outdoors

Applicator Phone:
Applicator Address:

Time

Contact

Phone

Comments

Introduction: Hello. I am calling from the Indian Health Service. The child care director (or designee)
from (TCCC NAME) indicated that your company applied pesticides at this facility within the last year.
(TCCC NAME) is participating in an environmental health survey which is looking at lead, allergens and
pesticides in child care centers. The child care director (or designee) has given us permission to ask you
about the specific pesticides used in that child care center. The purpose of this survey is to learn more
about how the child care center environment may affect the health of the children who spend many hours
in them. At this point, little is known about pesticide levels in tribal child care centers in our region. Could
you please take just five minutes to answer a few quick questions?

Q1. Do your records show that any pesticides were used indoors at (TCCC name/address) in the past 12
months?
YES (FILL OUT TABLE, THEN SKIP TO Q3)
NO (IF TCCC REPORTED INDOOR APPLICATION, SKIP TO Q2, ELSE GO TO Q3)
DON’T KNOW (IF TCCC REPORTED INDOOR APPLICATION, SKIP TO Q2, ELSE GO TO Q3)
REFUSE TO ANSWER (IF TCCC REPORTED INDOOR APPLICATION, SKIP TO Q2, ELSE GO
TO Q3)
a. What
pesticides were
used indoors?
(EPA Reg #, if
known)

P1. Pesticide 1

P2. Pesticide 2

P3. Pesticide 3

P4. Pesticide 4

P5. Pesticide 5

b. What was
its
formulation
? (Circle
one of the
following)
Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

c.

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

Where was
it applied?
(Circle all
that apply)

Kitchen
Bathroom
Multi Use Rm
Classroom
Other?
DK

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

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

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Month

Year

Month

Year

Month

Year

Month

Year

f.

What pest(s)
was being
targeted?
(Write-out)

Q2. The center said that you did apply a pesticide indoors, could you please check your work orders or
other records again?
FOUND PESTICIDE APPLICATION - INDOORS.............................1 (GO TO Q1a)
DID NOT FIND PESTICIDE APPLICATION - INDOORS.................2 (GO TO Q3)
COMMENT: ____________________________________________________

Q3. Do your records show that any pesticides were used outdoors at (TCCC name/address) in the past
12 months?
YES (FILL OUT TABLE, THEN SKIP TO END)
NO (IF TCCC REPORTED OUTDOOR APPLICATION, SKIP TO Q4, ELSE GO TO END)
DON’T KNOW (IF TCCC REPORTED OUTDOOR APPLICATION, SKIP TO Q4, ELSE GO TO
END)
REFUSE TO ANSWER (IF TCCC REPORTED OUTDOOR APPLICATION, SKIP TO Q4, ELSE
GO TO END)
a. What
pesticides were
used outdoors?
(EPA Reg #, if
known)

P1. Pesticide 1

P2. Pesticide 2

P3. Pesticide 3

P4. Pesticide 4

P5. Pesticide 5

b. What was
its
formulation
? (Circle
one of the
following)
Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

c.

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

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

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

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

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

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

Aerosol
Bait
Dust
Granule
Pellet
Other?
DK

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

Where was
it applied?
(Circle all
that apply)

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

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

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

Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK
Once
Weekly
Monthly
Quarterly
Semi-annually
Annually
Other?
DK

Month

Year

Month

Year

Month

Year

Month

Year

Month

Year

f.

What pest(s)
was being
targeted?
(Write-out)

Q4. The center said that you did apply a pesticide outdoors, could you please check your work orders or
other records again?
FOUND PESTICIDE APPLICATION - OUTDOORS.............................1 (GO TO Q3a)
DID NOT FIND PESTICIDE APPLICATION - OUTDOORS.................2 (GO TO END)
COMMENT: ____________________________________________________

END- Thank you very much for taking the time to answer my questions today.