Form 0923-0056 Study Questionnaire for Licensed Anglers (Paper) - 16JAN

Attachment 7b. Study Questionnaire for Licensed Anglers (paper)

Biomonitoring of Great Lakes Populations Program III

Form Approved

OMB No. 0923-0056

Exp. Date 07/31/2020

ACKNOWLEDGEMENT OF RECEIPT OF CONSENT MATERIALS

You should have received a copy of the Consent Form along with this survey. Please take a few minutes to read the Consent Form.

I have received and reviewed the Consent Form. I understand that completing this questionnaire implies my consent to do so.

CONTACT INFORMATION

This section will ask you for your contact information. This will help us get you your lab results and tell you about the results of this study.

1. What is your full name?
   First: __________________ Last: __________________ Middle initial: ___

2. Do you have a phone number where we can reach you? This can be the phone number of a friend, relative, or someone who will know how to find you.

Yes  2a. What is it? _____________________
2b. What type of phone number is this? Home Work Cell Other

No

Don’t know

Prefer not to answer

3. Do you have an email address?

Yes  3a. What is it? ________________________________________

No

Don’t know

Prefer not to answer

4. What is your address?

Street number and name: ____________________

Apartment unit or number: ______________

City: _____________________ State: _______ ZIP Code: _____________

ATSDR estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-17IY).

5. Is your mailing address different from your street address?

Yes  5a. What is your mailing address?

Street number and name: ____________________

Apartment unit or number: ______________

City: _____________________ State: _______ ZIP Code: _____________

No

Don’t know

Prefer not to answer

SEX, AGE, RACE, ETHNICITY

Now we will ask you some questions about your sex, age, race and ethnicity.

6. What is your sex?

Male

Female

7. What is your birthdate?

____ / _____ / _______

mm dd yyyy

8. Do you consider yourself to be Hispanic or Latino?

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

9. What race do you consider yourself to be?

American Indian or Alaska Native

Asian Answer #9a

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

9a. Are you of Burmese descent?

Yes

No

Prefer not to answer

RESIDENTIAL HISTORY

Now we will ask you some questions about where you have lived.

10. How long have you lived in the Milwaukee, Wisconsin area?

_____ years

Don’t know

Prefer not to answer

11. How long have you lived at your current address?

_____ years

Don’t know

Prefer not to answer

12. When was this home built? Please enter four digits for the year, such as 1999. If you are unsure what year it was built, please make your best guess.

Approximate year: __________

13. Have you lived anywhere outside the Milwaukee area?

Yes

No  SKIP to #15

Don’t know  SKIP to #15

Prefer not to answer  SKIP to #15

14. Where did you live before coming to Milwaukee?

14a. Location #1 (specify city, state, country): ________________________

How long did you live there? _____ years (Please round to the nearest full year)

Don’t know

Prefer not to answer

14b. Have you lived anywhere else before coming to Milwaukee?

Yes  Where did you live before coming to Milwaukee?

Specify city, state, country: ________________________

How long did you live there? _____ years (Please round to the nearest whole year.)

No  SKIP to #15

Don’t know

Prefer not to answer

FISH AND SHELLFISH EATEN IN THE LAST 30 DAYS

These next few sections will ask you about the fish and shellfish you eat. We will ask you about fish and shellfish that you may have bought at a store or restaurant, as well as fish and shellfish that you or someone you know caught from lakes, rivers, or streams in Wisconsin. First, we will ask several questions on fish and shellfish eaten in the last 30 days.

15. In the last 30 days, how many times did you eat SHELLFISH, such as shrimp, oysters, lobster, clams, crab, or crayfish?

_______ total number of shellfish meals eaten in the last 30 days

Don’t know

Prefer not to answer

16. In the last 30 days, how many times did you eat FISH such as fresh, canned, or frozen fish, fish fillets, fish sticks, fish sandwiches, and tuna fish?

_______ total number of fish meals eaten in the last 30 days

Don’t know  SKIP to #18

Prefer not to answer  SKIP to #18

17. In the last 30 days, how many of these fish meals were caught by you or someone you know from any lakes, rivers, and streams in Wisconsin? These are sometimes called ‘sport-caught fish’.

_______ total number of meals eaten in the last 30 days

Don’t know

Prefer not to answer

FISH EATEN IN THE LAST 12 MONTHS

Now we will ask you some questions about fish you ate that were caught by you or someone you know. These fish are sometimes called ‘sport-caught fish’ or ‘sportfish’. We will be asking you to estimate how many fish meals you have eaten in the last 12 months.

18. In the last 12 months, how many times did you eat any fish caught by you or someone you know?

__________ total number of meals in the last 12 months

Don’t know

Prefer not to answer

Questions 19-21 ask about fish caught in different lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin. Please refer to Image 1 at the back of this questionnaire which shows the lakes, rivers, and streams we are interested in.

18. In the last 12 months, have you eaten any fish caught by you or someone you know from the lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin, shown in Image 1? Please think about these locations only.

__________ total number of meals in the last 12 months

Don’t know

Prefer not to answer

18. Thinking about fish caught in any of the lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin, shown in Image 1, how has the total amount of fish you eat changed during the past five years?

Eat less

Same or about the same

Eat more

Don’t know

Prefer not to answer

18. The following questions are about types of fish you have eaten that were caught by you or someone you know. When answering these questions, please think only about fish caught in the lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin, shown in Image 1.

In the last 12 months, have you eaten:
	Yes	No	Don’t know	Prefer not to answer	If YES, approximately how many times did you eat it in the last 12 months?
Black crappie					Number: ______ Don’t know how many
Bluegill					Number: ______ Don’t know how many
Bullhead					Number: ______ Don’t know how many
Buffalo					Number: ______ Don’t know how many
Carp					Number: ______ Don’t know how many
Channel catfish					Number: ______ Don’t know how many
Chubs					Number: ______ Don’t know how many
Salmon (chinook or coho)					Number: ______ Don’t know how many
Lake whitefish					Number: ______ Don’t know how many
Muskellunge (Muskie)					Number: ______ Don’t know how many
Northern pike					Number: ______ Don’t know how many
Redhorse					Number: ______ Don’t know how many
Rockbass					Number: ______ Don’t know how many
Largemouth bass					Number: ______ Don’t know how many
Smallmouth bass					Number: ______ Don’t know how many
White bass					Number: ______ Don’t know how many
Sheepshead					Number: ______ Don’t know how many
Smelt					Number: ______ Don’t know how many
Walleye					Number: ______ Don’t know how many
White sucker					Number: ______ Don’t know how many
Yellow perch					Number: ______ Don’t know how many
White perch					Number: ______ Don’t know how many
Brown trout					Number: ______ Don’t know how many
Lake trout					Number: ______ Don’t know how many
Rainbow trout					Number: ______ Don’t know how many
Other fish types (please specify):					Number: ______ Don’t know how many
Other fish types (please specify):					Number: ______ Don’t know how many
Other fish types (please specify):					Number: ______ Don’t know how many

Questions 22-25 ask about fish caught specific lakes, rivers, and streams in southeastern Wisconsin. Each question is about a different area and will ask you to look at Images 8, 9, 10, or 11 at the back of this questionnaire.

18. In the last 12 months, have you eaten any fish caught in the lakes, rivers, and streams near the Milwaukee area, highlighted in Image 8?
    Yes
    No
    Don’t know
    Prefer not to answer
    
    

19. In the last 12 months, have you eaten any fish caught in the lakes, rivers, and streams near the Fond du Lac and Oshkosh areas, highlighted in Image 9 ?
    Yes
    No
    Don’t know
    Prefer not to answer
    
    

20. In the last 12 months, have you eaten any fish caught in the lakes, rivers, and streams near the Sheboygan and Manitowoc areas, highlighted in Image 10?
    Yes
    No
    Don’t know
    Prefer not to answer
    
    

21. In the last 12 months, have you eaten any fish caught in the lakes, rivers and streams near the Beaver Dam, West Bend, Waukesha, and Jefferson areas, highlighted in Image 11?
    Yes
    No
    Don’t know
    Prefer not to answer

PURCHASED FISH EATEN IN THE LAST 12 MONTHS

Now we will ask you to think about fish and shellfish you have bought in store, restaurant or market. We will be asking you to estimate how many fish meals you have eaten in the last 12 months.

18. These next questions will ask you about fish you have eaten which came from a store, restaurant, fish vendor, market, or supermarket.

Thinking about the last 12 months, have you eaten:
	Yes	No	Don’t know	Prefer not to answer	If YES, approximately how many times did you eat it in the last 12 months?
King mackerel					Number: ______ Don’t know how many
Tilefish					Number: ______ Don’t know how many
Shark					Number: ______ Don’t know how many
Swordfish					Number: ______ Don’t know how many
Salmon (including canned)					Number: ______ Don’t know how many
Canned light tuna					Number: ______ Don’t know how many
Canned white or albacore tuna					Number: ______ Don’t know how many
Fresh or frozen tuna					Number: ______ Don’t know how many
Tilapia					Number: ______ Don’t know how many
Halibut					Number: ______ Don’t know how many
Cod					Number: ______ Don’t know how many
Shellfish (such as shrimp, mussels, etc.)					Number: ______ Don’t know how many
Other fish not listed here, please specify:					Number: ______ Don’t know how many

FISH CLEANING AND COOKING PRACTICES

We will now ask you some questions about how you typically clean and cook the fish you eat.

18. These next questions will ask you about how you clean and prepare the fish you eat.

When preparing fish, how often do you eat or prepare meals using:	Never	Sometimes	Always	Don’t know	Prefer not to answer
The skin of the fish
The head of the fish
The guts, organs, or other innards of the fish
The belly fat of the fish

18. The next questions will ask you about how you cook fish.

When cooking fish, how often do you:	Never	Sometimes	Always	Don’t know	Prefer not to answer
Smoke or dry fish
Pickle fish
Use fish to make fish paste
Pan fry fish
Grill, or roast fish
Deep fry fish
Boil or poach fish
Use fish or fish parts to make broth/stock, curry, or soup

18. Please look at Image 2 of a 6 ounce serving of cooked fish, found at the back of this questionnaire. Compared to this model, would you say that a typical meal of fish you eat is usually:

Less (smaller than the picture)

Same or about the same

More (larger than the picture)

Don’t know

Prefer not to answer

18. During which season(s) do you eat fish? (check all that apply)
    Spring (March, April, May)
    Summer (June, July, August)
    Fall (September, October, November)
    Winter (December, January, February)
    Don’t know
    Prefer not to answer
    
    

19. During which season(s) do you catch fish? (check all that apply)
    Spring (March, April, May)
    Summer (June, July, August)
    Fall (September, October, November)
    Winter (December, January, February)
    I don’t catch fish
    Don’t know
    Prefer not to answer

ADVISORY AWARENESS

Now we will be asking you a few questions about the safe-eating guidelines for fish caught in Wisconsin. We are not asking you about the regulations on what size of fish and how many fish you can keep from a water body. These questions are about the health-based advisories written to protect you from contaminants like mercury and PCBs.

18. Have you heard about the safe-eating guidelines for fish caught in Wisconsin?

Yes

No  SKIP to #35

Don’t know  SKIP to #35
Prefer not to answer  SKIP to #35

33. How much would you say that you know about these guidelines?
Nothing
A little bit
Some
Quite a bit
A great deal
Prefer not to answer

34. How closely do you follow the advice provided in these guidelines?
Not at all
A little bit
Somewhat
Very
Extremely
Prefer not to answer

35. Have you ever heard about the safe-eating guidelines for fish caught in the Milwaukee River and harbor mouth at Lake Michigan, Menomonee River, Lincoln Creek, or Cedar Creek?
Yes
No  SKIP to #38
Don’t know  SKIP to #38
Prefer not to answer  SKIP to #38

36. How much would you say that you know about these guidelines?
Nothing
A little bit
Some
Quite a bit
A great deal
Prefer not to answer

37. How closely do you follow the advice provided in these guidelines?
Not at all
A little bit
Somewhat
Very
Extremely
Prefer not to answer

38. Have you ever made any of the following changes to avoid contaminants such as mercury and PCBs? (check all that apply)

Eaten fewer fish meals
Eaten different types or species of fish

Avoided eating certain parts of fish (head, fat, belly, skin)
Avoided eating fish from some fishing locations

None of these
Prefer not to answer

39. The next questions will ask you how you get information about fish consumption advice, and how useful you think these sources are. Remember, we are asking you about the safe-eating guidelines, NOT any regulations about size and number of fish you can keep. Some of these questions will ask you to look at the images found at the back of this questionnaire.

Do you get information about Wisconsin fish consumption advice from:		If yes:
		How useful is this source of information?	Do you find this source easy to understand?	Do you use this source when making decisions about eating fish?
a. Fishing club newsletters or websites or other sports club publications	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
b. Wisconsin Department of Natural Resources website or publications	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
c. Wisconsin Department of Health Services website or publications	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
d. Federal agencies, such as the Environmental Protection Agency (EPA) or the Food and Drug Administration (FDA)	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
e. Friends or family members	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
f. Fishing regulations booklet distributed with fishing license, see Image 3	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
g. Choose Wisely – a health guide for eating fish in Wisconsin, see Image 4	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
h. Tackle or sporting goods stores	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
i. County health office or website	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
j. Grocery store or food market	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
k. Fish eating guidelines posted near waters that I fish, see Image 5	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
l. Television, radio and/or newspaper messages/reports	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
m. My health care provider	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
n. Charter boat operators or guides	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer
o. iPhone/Smartphone apps (e.g., DNR Pocket Ranger Fish and Wildlife app), see Image 6.	Yes No Prefer not to answer	Not useful Somewhat useful Very useful Prefer not to answer	Yes No Prefer not to answer	Yes No Prefer not to answer

WILD BIRDS AND ANIMALS

Now we will ask you about any wild birds or animals you may have eaten in the last 12 months.

These next questions will ask you about the types of wild animals and waterfowl you have eaten which were caught near the lakes, rivers, and streams highlighted in Image 8, found at the back of this questionnaire. Images 7a-h at the back of this questionnaire show examples of these wild animals and waterfowl.

40. Thinking about the last 12 months, have you eaten:
	Yes	No	Don’t know	Prefer not to answer	If YES, approximately how many times did you eat it in the last 12 months?
a. Waterfowl (ducks, geese, or seagulls)					Number: ______ Don’t know how many
b. Crows or other scavenger birds					Number: ______ Don’t know how many
c. Deer					Number: ______ Don’t know how many
d. Frogs or toads					Number: ______ Don’t know how many
e. Rats or mice					Number: ______ Don’t know how many
f. Rabbits					Number: ______ Don’t know how many
g. Groundhogs					Number: ______ Don’t know how many
h. Squirrels					Number: ______ Don’t know how many

41. In the past 12 months, have you eaten waterfowl (such as ducks or geese) that were harvested in any other locations not highlighted in Image 1 (found at the back of this questionnaire)?

YES: 41a. Please tell us where: _________________

NO

Don’t know

Prefer not to answer

LIFESTYLE AND ACTIVITIES

Now we will ask you some questions about your lifestyle and some activities you might do in your free time.

42. On most days, do you take or use any herbal medicine or supplements?

Yes

No

Don’t know

Prefer not to answer

43. On most days, do you take or use fish oil supplements?

Yes

No

Don’t know

Prefer not to answer

44. Have you smoked at least 100 cigarettes (or 5 packs) in your lifetime?

Yes

No  SKIP to #47

Don’t know  SKIP to #47

Prefer not to answer  SKIP to #47

45. Do you smoke cigarettes now?

Yes

No  SKIP to #47

Don’t know  SKIP to #47

Prefer not to answer  SKIP to #47

46. How many cigarettes do you smoke per day? (1 pack=20 cigarettes)

1-5 per day

6-10 per day

11-20 per day (>1/2 and <1 pack per day)

>20 per day (>1 pack per day)

Don’t know

Prefer not to answer

47. Do you use chewing tobacco or snuff?

Yes

No  SKIP to #49

Don’t know  SKIP to #49

Prefer not to answer  SKIP to #49

48. How often do you use chewing tobacco or snuff?

Daily

Weekly

Monthly

Don’t know

Prefer not to answer

49. Please look at Image 8 (found at the back of this questionnaire) of the lakes, rivers, and streams in the Milwaukee area. Do you swim, dive, or wade in any of these lakes, rivers, and streams?

Yes: 49a. How many times in the past year? ______

No

Don't know

Prefer not to answer

50. Have you or anyone else in your household done any of the following activities in the last 12 months?

Activity:	Yes	No	Don’t know	Prefer not to answer
Dyeing material
Electronics assembly
Gardening or farming
Glass crafting
Metal work
Painting and glazing
Packing ammunition
Print making
Wood working
Home renovation/repair

HOUSEHOLD INFORMATION

Now we will ask you a few questions about your household, including how many people live in your home with you.

51. Do you live alone, or with others?

With others  51a. How many people live with you? Please count all adults, children

and infants. Do not count yourself. ________

Live alone  SKIP to #50

Don’t know  SKIP to #50

Prefer not to answer  SKIP to #50

52. Do you live with any women between the ages of 15 and 45 years old?

Yes  52a. How many women between the ages of 14 and 45 live with you? _______

No  SKIP to #53

Don’t know  SKIP to #53

Prefer not to answer  SKIP to #53

52b. Do any of these women eat locally caught fish?
Yes

No

Don’t know

Prefer not to answer

53. Do you live with any children under the age of 15?

Yes  53a. How many children under the age of 15 live with you? _______

No  SKIP to #54

Don’t know  SKIP to #54

Prefer not to answer  SKIP to #54

53b. Do any of these children eat locally caught fish?

Yes

No

Don’t know

Prefer not to answer

EDUCATION, MARITAL STATUS, WORK HISTORY, AND INCOME

Now we will ask some questions about your work history, education, income, and marital status.

54. What is the highest grade level of school or degree you have completed?

8th grade or less

Some high school, no diploma or GED

High school diploma or GED

Some college, no diploma

Associate degree

Bachelor’s degree

Postgraduate, professional, or doctoral degree

Don’t know

Prefer not to answer

55. What is your current marital status?

Married

Living with someone in a marriage-like relationship

Separated

Divorced

Widowed

Never married
Prefer not to answer

56. Do you currently work outside the home?

Yes, Full-time (answer 56a)

Yes, Part-time (answer 56a)

No  SKIP to #57

Don’t know SKIP to #57

Prefer not to answer SKIP to #57

56a. What is your current job?

Title_______________________________

Who is your employer? ___________________________________________

How many hours a week do you work? _____ hours per week

What are your usual activities or duties? __________________________________

56b. Do you have a second job?

Yes  answer 56bi

No  SKIP to #57

Don’t know  SKIP to #57

Prefer not to answer  SKIP to #57

56bi. What is your second job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties?__________________________________

56c. Have you worked at any (other) job in the past year?

Yes, Full-time answer 56ci

No  SKIP to #57

Don’t know  SKIP to #57

Prefer not to answer  SKIP to #57

56ci. What was this other job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties?__________________________________

57. Can you tell me your total family income in 2017 before taxes? (check one only)

Less than $15,000

$15,000 to less than $25,000

$25,000 to less than $35,000

$35,000 to less than $50,000

$50,000 to less than $75,000

$75,000 to less than $100,000

$100,000 or more

Don’t know

Prefer not to answer

HEALTH HISTORY

These next questions will ask you about any health conditions you have or have had.

Have you ever been told by a doctor that you had/have any of the following health conditions:
58. Heart/Circulatory Conditions:		Yes	If yes: year of diagnosis	No	Don’t know	Prefer not to answer
Coronary heart disease
Heart attack
Angina (pain from coronary heart disease)
Hypertension or high blood pressure
Stroke
High fat or cholesterol in your blood
Aneurysm
59. Thyroid conditions:		Yes	If yes: year of diagnosis	No	Don’t know	Prefer not to answer
Benign (non-cancerous) thyroid tumor
Hashimoto’s Disease
Grave’s Disease
An underactive thyroid or hypothyroidism
An overactive thyroid or hyperthyroidism
A goiter or enlarged thyroid gland
Some other thyroid or endocrine problem : __________________
60. Liver conditions:		Yes	If yes: year of diagnosis	No	Don’t know	Prefer not to answer
Hepatitis
Cirrhosis of the liver
Yellow jaundice
Fatty liver disease, not caused by drinking alcohol)
Some other type of liver condition: _________________
61. Other health conditions:		Yes	If yes: year of diagnosis	No	Don’t know	Prefer not to answer
Diabetes
Pre-diabetes (impaired fasting glucose, impaired glucose tolerance, borderline diabetes or higher blood sugar than normal but not high enough to be called diabetes or sugar diabetes)
Chronic kidney disease (CKD; chronic renal insufficiency)
Porphyria (decreased red blood cell production due to abnormal porphyrin metabolism)
Cancer	If yes, what kind of cancer(s) were you diagnosed with (please write below)?		What years were you diagnosed with each cancer?
	Type 1:		Type1:
	Type 2:		Type2:
	Type 3:		Type 3:

PRESCRIPTION MEDICATIONS

These next questions will ask you about medications you may currently be taking.

Are you currently taking prescription medications for:	Yes	No	Don’t know	Prefer not to answer
62. A thyroid condition
63. Diabetes	YES IF YES, what kind: Insulin Oral medication Both
64. High blood pressure
65. High cholesterol
66. Other health conditions

If you are a male, we have no more questions for you at this time. Please remember to bring this questionnaire with you to your in-person appointment. Thank you for completing this questionnaire.

If you are a female, please answer these questions about reproductive history.

REPRODUCTIVE HISTORY - FEMALE

67. Have you ever been pregnant?

Yes: 67a. How many times have you been pregnant? _______

No  go to go to END SURVEY

Don’t know  go to go to END SURVEY

Prefer not to answer  go to go to END SURVEY

68. Did any of these pregnancies result in a live birth?

Yes  68a. How many pregnancies resulted in live birth? ______

Never  go to go to END SURVEY

Don’t know  go to go to END SURVEY

Prefer not to answer go to go to END SURVEY

69. Have you ever breastfed any children?

Yes answer 69a.

No  go to go to END SURVEY

Don’t know  go to END SURVEY

Prefer not to answer  go to END SURVEY

69a. Tell me about the children you have breastfed from the first to the most recent child, including any children you are breastfeeding now.

	Birth Year (YYYY)	Birthplace (city/state/country)	Number of months breastfeeding?	If number of months is unknown ask: At what age did they stop breast feeding?
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th

END OF QUESTIONNAIRE

Thank you for completing this questionnaire. Please remember to bring it with you for your in-person appointment.