BITM Eligibility Survey

Appendix B. Eligibility Survey

BITM Eligibility Survey

Thank you for your interest in the Backyard Integrated Tick Management study. This is
a joint study between Western Connecticut State University’s Tickborne Disease
Prevention Laboratory, the University of Rhode Island, and the Centers for Disease
Control and Prevention. This study seeks to better understand if tickborne diseases, such
as Lyme disease, can be prevented with the use of Integrated Tick Management, which
includes pesticide sprays and bait boxes (a rodent-targeted method of tick control).
The following survey will be used to help determine if your household meets the necessary
criteria for inclusion in the study. By answering the questions on this survey you are
indicating your interest to participate, but you are under no obligation to enroll in the study.
We sincerely thank you for your time and interest to help us research new methods for
protecting human health. If your household meets the eligibility criteria, our study
coordinator will follow-up with you about enrolling in the study.
WCSU IRB Approval #1617-93

1. How did you hear about this survey?
Postcard in the mail
Friend/Neighbor
University website
Other (please specify)

2. If you received a postcard about this study, please enter the flyer code. If you did not receive
a postcard, you may skip this question.

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3. Are you living in one of the following towns in Connecticut: Bethel, Newtown, Ridgefield,
Westport or one of the following towns in Rhode Island: Jamestown, North Kingstown, or South
Kingstown?
Yes
No

* 4. Please enter your contact information so we may follow-up with you if needed.
First Name

Last Name
Street Address
Town
State
Zip Code
Phone Number
E-Mail

5. What is the best time to contact you if we have follow-up questions? Select all that apply.
8 AM - 10 AM
10 AM - Noon
Noon - 2 PM
2 PM - 4 PM
4 PM - 6 PM
6 PM - 9 PM

* 6. Do you speak English?
Yes
No

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* 7. Are you at least 18 years of age?
Yes
No

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8. Are you living in a free-standing home with a surrounding yard?
Yes
No

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9. Please enter the e-mail address that you use most frequently.
I don't have an e-mail address that I use frequently.
Please use this e-mail address for correspondence:

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10. Are you able to provide consent to receive property treatment on behalf of your household?
Yes
No
Don't know

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11. Do three or more people live in your household?
Yes
No

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12. Do you have standing water (e.g., stream, pond, etc.) on your property or within 100 feet of
your property edge?
Yes
No
Don't know

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13. Do you reside at your home during the summer (e.g., May-August), including weekends,
such that this is your permanent, year-round residence?
Yes
No
Don't know

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14. Does your yard or property include, or is bordered by, any woody or brushy areas with leaf
litter on the ground?
Yes
No
Don't know

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BITM Eligibility Survey

15. Do you have an intact deer fence (i.e., a fence greater than 5 ft in height) that encloses your
property on all sides?
Yes
No
Don't know

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16. Is your yard or total property between ½ and 3 acres in size?
Yes
No
Don't know

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BITM Eligibility Survey

17. In the last two summers (2015 or 2016), have you, a household member, and/or a licensed
commercial pesticide company applied a product (synthetic or organic) to your yard for the
purpose of insect, tick, or mosquito control?
Yes
No
Don't know

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18. If a company applied the product, please enter the name of the company.
Did not use a company.
Don't know
Name of Company

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19. Was the chemical applied to your property one of the following chemical names: bifenthrin,
carbaryl, cyfluthrin, deltamethrin, lambda-cyhalothrin, permethrin, pyrethrin?
Yes
No
Don't know
Other chemical name

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20. Was the chemical you applied to your property one of the following trade names: Talstar,
Ortho products, Sevin, Tempo, Powerforce, Suspend, DeltaGard, Astro, Bonide products,
TenGard SFR, Pyrenone, Kicker, Organic Solutions All Crop Commercial & Agricultural
Multipurpose Insecticide?
Yes
No
Don't know
Other trade name

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BITM Eligibility Survey

21. Since two summers ago (May 2015) do you know if either of your next-door neighbors
applied or used a licensed commercial pesticide company to apply a product (synthetic or
organic) to their yards for the purpose of insect, tick, or mosquito control?
Yes
No
Don't know

22. If yes, please enter the name of the company and/or product. If you don't know, please enter
"Don't know."

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BITM Eligibility Survey

I’m sorry, but we at this time, we can only enroll English-speaking participants. Thank you
so much for your interest in this study. Please check our website for study news and to
learn about future opportunities.

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BITM Eligibility Survey

I’m sorry, but we are only enrolling people who are at least 18 years of age. Thank you so
much for your interest in this study. Please check our website for study news and to learn
about future opportunities.

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BITM Eligibility Survey

I’m sorry, but we are only enrolling people with freestanding homes that have yards.
Thank you so much for your interest in this study. Please check our website for study news
and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, but we are only enrolling people in the communities listed. Thank you so much
for your interest in this study. Please check our website for study news and to learn
about future opportunities.

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BITM Eligibility Survey

I'm sorry, but we are only enrolling people who have an e-mail address that they use
frequently. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we can only enroll people who are able to give consent for treatments to take
place on their property. Thank you so much for your interest in this study. Please check our
website for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling households in which three or more people reside.
Thank you so much for your interest in this study. Please check our website for study news
and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling people who do not have water on or near their property.
Thank you so much for your interest in this study. Please check our website for study news
and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling people who reside in their homes during the summer
months. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling people who have yards with woody or brushy habitat and
leaf litter. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are not enrolling people who have a fence greater than 5 ft. tall enclosing
their property. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling people who have a property that is between 1/2 acre and 3
acres in size. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are only enrolling people who have not applied pesticide in the past two
years. Thank you so much for your interest in this study. Please check our website
for study news and to learn about future opportunities.

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BITM Eligibility Survey

I'm sorry, we are not enrolling people who used one of those pesticides.
Thank you so much for your interest in this study. Please check our
website for BITM Study news and to learn about future opportunities.

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BITM Eligibility Survey

Thank you so much for your time. Our study coordinators will evaluate your answers and
be in touch with you if you are eligible to enroll in the study. We are hopeful to partner with
you to discover new ways to prevent tickborne disease!

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