Sample - ACE short form

Appendix C: ACE Short Form

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

Form Version 081817

EVENT CODE:|___|___| SITE # |___|___| INTERVIEWER ID|___|___|___| DATE:|___|___| - |___|___ | - |___|___| TIME STARTED |___|___| : |___|___ | |___|

M M D D Y Y H H M M A/P

ACE SHORT FORM

Hello, my name is _______________________. We are collecting emergency-related health information that is important to us and affected people. May I read you a consent statement, and then ask you some health questions?

We are getting information from people exposed to this event so they can receive information about exposures, health, or services. You also may be contacted at a later date to complete a longer form. Our questions will take about 5-10 minutes. You can choose not to answer any question you wish. All the information will be kept confidential to the extent allowed by law.

PARTICIPANT INFORMATION 1. Do you speak English? 1  Yes 2  No IF NO: What language do you prefer?__________________________ 2. Data obtained from: 1  Participant 2  Proxy 3  Medical/Medical Examiner’s/Other Record 4  Other, SPECIFY:_____________________________  Don’t Know 99  Refuse to answer 3. What is (your/participant’s) full name? FIRST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| LAST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| M. I.|__| 4. How old (are you/is participant)? _____________  Don’t Know 99  Refuse to answer 5. If necessary: What is (your/participant’s) sex? 1  Male 2  Female 98  Not Determined 99  Refuse to answer 6. What is (your/participant’s) date of birth? |___|___| - |___|___| - |___|___|___|___| MM DD YYYY  Don’t Know 99  Refuse to answer 7. A. What is (your/participant’s) home address? STREET ____________________________________________ _____________________________________________ CITY _________________________STATE ___ ZIP_ _ _ _ _ 98  Don’t Know 99  Refuse to answer B. How many people live at this address? ____________ 98  Don’t Know 99  Refuse to answer What is (your/participant’s) A. Home telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 96  None 98  Don’t Know 99  Refuse to answer B. Work telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 96  None 98  Don’t Know 99  Refuse to answer C. Cell/other phone number? (__ __ __) __ __ __ - __ __ __ __ 96  None 97  Same As Home Phone 98  Don’t Know 99  Refuse to answer 9. (Do you/does participant) have an email address? 1  Yes, SPECIFY: 2  No ──────────────────────── This information is collected under the authority Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA), commonly known as the "Superfund" Act, as amended by the Superfund Amendments and Reauthorization Act (SARA) of 1986 and the Public Health Service Act (42 USC Sec. 301 [241]). ATSDR estimates that the average public reporting burden for this collection of information as 7 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 CDC/ATSDR Information Collection Review Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0923-0051). 98  Don’t Know 99  Refuse to answer

10. What is (your/participant’s) employment status? 1  Employed, SPECIFY EMPLOYER’S NAME: _______________ ___________________________________________________________ 2  Not employed 3  Self-employed 4  Not Applicable 98  Don’t Know 99 Refuse to Answer PROXY OR CLOSE FRIEND/RELATIVE INFORMATION (If data obtained NOT from participant, please skip to question 13.) 11. Is there someone who does not live with (you/participant) who can always reach (you/participant)? 1  Yes 2  No ┐ 98  Don’t Know │► SKIP TO QUESTION 22 99  Refuse to Answer ┘ 12. What is (your/that person’s) full name? FIRST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| LAST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| M. I.|__| 13. What is (your/his/her) home address? STREET ____________________________________________ ____________________________________________ CITY _________________________STATE ___ ZIP_ _ _ _ _ 95  Same As participant 98 Don’t Know 99 Refuse to Answer 14. What is (your/his/her) A. Home telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 95  Same As participant 96  None 98  Don’t Know 99  Refuse to Answer B. Work telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 96  None 98  Don’t know 99  Refuse to Answer C. Cell/other phone number? (__ __ __) __ __ __ - __ __ __ __ 96  None 97 Same As Home Phone 98  Don’t Know 99  Refuse to Answer 15. (Do you/does he/she) have an email address? 1  Yes, specify: 2  No ──────────────────────── 98  Don’t Know 99  Refuse to Answer OTHER CLOSE FRIEND/RELATIVE INFORMATION 16. Is there (someone else/someone)who does not live with (you/participant) who can always reach (you/participant)? THIS PERSON MUST LIVE AT A DIFFERENT ADDRESS THAN THE PERSON LISTED IN QUESTION 13.) 1  Yes 2  No ┐ 98  Don’t Know │► SKIP TO QUESTION 22 99  Refuse to Answer ┘

Form Version 081817

17. What is that person’s full name? FIRST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| LAST |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| M. I.|__| 18. What is (his/her) home address? STREET ____________________________________________ ____________________________________________ CITY _________________________STATE ___ ZIP_ _ _ _ _ 98  Don’t Know 99  Refuse to Answer 19. What is (his/her) A. Home telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 96  None 98  Don’t Know 99  Refuse to Answer B. Work telephone number? (__ __ __ ) __ __ __ - __ __ __ __ 96  None 98  Don’t Know 99  Refuse to Answer C. Cell/other phone number? (__ __ __) __ __ __ - __ __ __ __ 96  None 97  Same as Home Phone 98  Don’t Know 99 Refuse to Answer 20. Does (he/she) have an email address? 1  Yes, SPECIFY: 2  No ──────────────────────── 98  Don’t Know 99  Refuse to Answer EXPOSURE INFORMATION Now I’m going to ask you just a few questions about (your/ participant’s) experience with this event. 21. (Were you/Was participant) exposed to this event as (CHECK ALL THAT APPLY) : 1  A resident 2  A passerby 3  An employee 4  A responder or rescue worker 5  A government official 6  A clean-up worker 7  An non-governmental organization/site volunteer 98  Don’t Know 99  Refuse to Answer 22. (Were you/was participant) at the event site when the event started? 1  Yes 2  No 98  Don’t Know 99  Refuse to Answer 23. At the start of the event on [DATE] at [TIME], at what address (were you/was participant)? ____________________ __________________________________________________ 98  Don’t Know 99  Refuse to Answer 24. What was the name of nearest building to (you/participant)? __________________________________________________ 98  Don’t Know 99  Refuse to Answer 25. What was the nearest intersection? ____________________ __________________________________________________ 98  Don’t Know 99  Refuse to Answer 26. What was the nearest landmark? _____________________ _______________________________________________________________ 98  Don’t Know 99  Refuse to Answer 27. At the start of the event, (were you/was participant) (CHECK ALL THAT APPLY): 1  Inside a building or structure 2  Inside a car or other vehicle 3  Outside 4  At some other location, SPECIFY: ________________ _________________________________________________________ 98  Don’t Know 99  Refuse to Answer

28. As a result of the event, did (you/participant) get injured or ill? 1  Yes, DESCRIBE: __________________________________ 2  No 98  Don’t Know 99  Refuse to Answer 29. Before the event, did (you/participant) have any of the following conditions? (CHECK ALL THAT APPLY) 1  Chronic illness 2  Physical disability 3  Other disability 4  None ┐ 98  Don’t Know │► SKIP TO QUESTION 32 99  Refuse to Answer ┘ 30. Please describe your condition: ________________________ ___________________________________________________ ___________________________________________________ 31. IF PARTICIPANT IS FEMALE LESS THAN 12 YEARS OLD OR MALE, SKIP TO QUESTION 33. OTHERWISE ASK: (Are you/is participant) pregnant? 1  Yes 2  No 98  Don’t Know 99  Refuse to Answer 32. As a result of this event, (are you/is participant) personally in need of any of the following? (CHECK ALL THAT APPLY): 1  Medications/supplies 2  Medical care 3  Water 4  Food 5  Shelter 6  Utilities 7  Other, SPECIFY: 8  None _______________________________ 98  Don’t Know 99  Refuse to Answer 33. Event-specific question 1. 1  Response Option 1 2  Response Option 2 3  Response Option 3 4  Response Option 4 5  Response Option 5 6  Response Option 6 98  Don’t Know 99  Refuse to Answer 34. Event-specific question 2. 1  Response Option 1 2  Response Option 2 3  Response Option 3 4  Response Option 4 5  Response Option 5 6  Response Option 6 98  Don’t Know 99  Refuse to Answer 35. Event-specific question 3. 1  Response Option 1 2  Response Option 2 3  Response Option 3 4  Response Option 4 5  Response Option 5 6  Response Option 6 98  Don’t Know 99  Refuse to Answer 36. Event-specific question 4. 1  Response Option 1 2  Response Option 2 3  Response Option 3 4  Response Option 4 5  Response Option 5 6  Response Option 6 98  Don’t Know 99  Refuse to Answer That completes our interview. Thank you very much for your time.

TO BE COMPLETED BY INTERVIEWER 37. INDICATE THE SEVERITY OF THE EFFECT ON PARTICIPANT 1  No Obvious Effect 2  Affected, Ambulatory 3  Unconscious, Non-Ambulatory, Or Badly Injured/Ill 4  Dead 5  Not Applicable 98  Don’t Know