Form 0923-0056 Study Questionnaire - Burmese Immigrants and their Desce

Attachment 7d. Study Questionnaire for Burmese Immigrants and their Descendants

Biomonitoring of Great Lakes Populations Program III

Form Approved

OMB No. 0923-0056

Exp. Date 07/31/2020

Study Questionnaire for Burmese Immigrants and their Descendants

Interviewer instructions: Please record the date of the interview and the participant’s ID number below before beginning the interview. Please confirm completion of the Contact Information Form.

DATE (MM/DD/YYYY): __ / __ / ____

STUDY ID: ______________________

Mark this box to confirm that the Contact Information Form has been completed. If not, complete this form with the participant now.

SEX, AGE, RACE, ETHNICITY

I will start by asking you some questions about your sex, age, race and ethnicity.

1. What is your sex/gender?

Male

Female

2. What is your birthdate?

____ / _____/ _______

mm dd yyyy

Unknown  2a. What is your age? ________ years

3. In what country were you born?

United States

Burma/Myanmar

Thailand

Malaysia

Other country  3a. Specify: _________________________

Don’t know

Prefer not to answer

ATSDR estimates the average public reporting burden for this collection of information as 40 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).

4. What is your ethnicity or tribe?

Burman

Chin

Kachin

Karenni

Karen

Mon

Rakhine
Rohingya

Other,  4a. Specify: _________________________

Don’t Know

Prefer not to answer

RESIDENTIAL HISTORY

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

5. How long have you lived in the United States?

_____ years

Don’t know

Prefer not to answer

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

_____ years

Don’t know

Prefer not to answer

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

_____ years

Don’t know

Prefer not to answer

8. When was this home built?

Approximate year: __________

9. Have you lived anywhere outside the Milwaukee area?

Yes

No  Skip to #11

Don’t know  Skip to #11

Prefer not to answer  Skip to #11

10. Where did you live before coming to Milwaukee?

10a. Location #1 (specify city, state, country): ________________________

Was this a Refugee Camp? Yes No
How long did you live there? _____ years

Interviewer: please round to the nearest year

Don’t know

Prefer not to answer

10b. Location #2 (specify city, state, country): ________________________

Was this a Refugee Camp? Yes No
How long did you live there? _____ years

Interviewer: please round to the nearest year

Don’t know

Prefer not to answer

FISH AND SHELLFISH

I will now ask you about the fish and shellfish you eat. I 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, I will ask several questions on fish and shellfish eaten in the last 30 days.

1. 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

12. 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 #14

Prefer not to answer  Skip to #14

13. 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’.

_______ number of locally-caught fish meals eaten in the last 30 days

Don’t know  Skip to #14

Prefer not to answer  Skip to #14

FISH EATEN IN THE LAST 12 MONTHS

Now I 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’. I will be asking you to estimate how many fish meals you have eaten in the last 12 months. I understand that you might need a few minutes to think about these questions, so please take your time.

14. In the last 12 months, how many times have you eaten fish caught by you or someone you know?
__________ total number of meals in the last 12 months

Don’t know  Answer Question 16, then SKIP to #18

Prefer not to answer  Answer Question 16, then SKIP to #18

15. Please look at this picture of lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin. Thinking about the last year, how many times have you eaten fish caught by you or someone you know from the lakes, rivers, and streams shown here? Please think about these locations only. (Will include an image of the Milwaukee and surrounding southeastern area of WI)
__________ total number of meals in the last 12 months

Don’t know  Answer Question 16, then SKIP to #18

Prefer not to answer  Answer Question 16, then SKIP to #18

16. Please look at the picture of lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin. For fish caught in any of the lakes, rivers, and streams in the picture, how has the total amount of fish you eat changed during the past five years? (Will include map of Milwaukee and surrounding southeastern area of WI)

Eat less

Same or about the same

Eat more

Don’t know

Prefer not to answer

16. Please look at this picture of lakes, rivers, and streams in Milwaukee and the surrounding southeastern area of Wisconsin. 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 pictured and listed here. (Will include map of Milwaukee and surrounding southeastern area of WI)

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

16. In the last 12 months, have you eaten any fish caught in lakes, rivers, and streams near the Milwaukee area highlighted in this map? ( interviewer show map of this area)

Yes
No
Don’t know
Prefer not to answer

16. 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 this map? (interviewer show map of this area)

Yes
No
Don’t know
Prefer not to answer

16. 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 this map? ( interviewer show map of this area)

Yes
No
Don’t know
Prefer not to answer

16. 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 this map? ( interviewer show map of this area)

Yes
No
Don’t know
Prefer not to answer

PURCHASED FISH EATEN IN THE LAST 12 MONTHS

Now I will ask you to think about fish and shellfish you have bought in store, restaurant or market. I will be asking you to estimate how many fish meals you have eaten in the last 12 months. I understand that you might need a few minutes to think about these questions, so please take your time.

16. These next questions will ask you about fish you have eaten which came from a store, restaurant, fish vendor, market, or supermarket. Will include a picture of each type of fish)

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 PASTE

23. Do you eat fish paste, sometimes called “nya u” or “ngape”?
Yes How often?______ times per (circle one) week month year

No  SKIP to #24

Don’t know  SKIP to #24

Prefer not to answer  SKIP to #24

24. Where do you get your fish paste? (check all that apply)
Homemade

Purchased in a store or market  SKIP to #24
Don’t know  SKIP to #24

Prefer not to answer  SKIP to #24

25. Is the homemade fish paste made from fish caught in nearby waters?
Yes
No  SKIP to #24
Don’t know  SKIP to #24
Prefer not to answer  SKIP to #24

26. What kinds of fish are used to make homemade fish paste? (check all that apply) (There will be a picture to help identify each type of fish. The picture will have common and translated fish names).

Black crappie Northern pike Walleye

Bluegill Redhorse White sucker

Bullhead Rock bass Yellow perch

Buffalo Lake whitefish Muskellunge (muskie)

Carp Largemouth bass Brown trout

Channel catfish Smallmouth bass Lake trout

Chubs Smelt Rainbow trout

Chinook salmon Coho salmon White bass

Sheepshead White perch

Other species, specify: ________________________________________
Don’t know

Prefer not to answer

27. What parts of the fish are used to make homemade fish paste? (check all that apply) (There will be a picture to help identify parts of the fish)

Whole fish

Flesh/muscle and skin only

Flesh only

Whole fish with head and tail removed

Other: (specify) ___________________________

Don’t know

Prefer not to answer

FISH CLEANING AND COOKING PRACTICES

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

28. These next questions will ask you about how you clean and prepare the fish you eat. Here is a picture to show you the different parts of the fish we are asking about. (Will include picture of each fish part)

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

29. 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
Grill, or roast fish
Deep fry fish
Boil or poach fish
Use fish or fish parts to make broth/stock, curry, or soup

30. Please look at this picture of a 6 ounce serving of cooked fish. Compared to this model, would you say that a typical meal of fish you eat is usually: (Will include picture to illustrate serving size)

Less (smaller than the picture)

Same or about the same

More (larger than the picture)

Don’t know

Prefer not to answer

31. 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

32. 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 do not 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.

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

Yes

No  Skip to #36

Don’t know  Skip to #36
Prefer not to answer  Skip to #36

34. 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

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

36. 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 #39
Don’t know  Skip to #39
Prefer not to answer  Skip to #39

37. 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

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

39. 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

40. The next questions will ask you about 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.

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?
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
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
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
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
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
Fishing regulations booklet distributed with fishing license, pictured here	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
Choose Wisely – a health guide for eating fish in Wisconsin, pictured here	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
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
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
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
Fish eating guidelines posted near waters that I fish (see example picture)	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
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
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
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
iPhone/Smartphone apps (e.g., DNR Pocket Ranger Fish and Wildlife app), pictured here	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 I will ask you about any wild birds or animals you may have eaten in the last 12 months.

41. These next questions will ask you about the types of wild animals and waterfowl you have eaten, which were harvested near areas identified in this picture. (Will include map/picture of locations, and picture of each bird/animal)

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?
Waterfowl (ducks, geese, or seagulls)					Number: ______ Don’t know how many
Crows or other scavenger birds					Number: ______ Don’t know how many
Deer					Number: ______ Don’t know how many
Frogs or toads					Number: ______ Don’t know how many
Rats or mice					Number: ______ Don’t know how many
Rabbits					Number: ______ Don’t know how many
Groundhogs					Number: ______ Don’t know how many
Squirrels					Number: ______ Don’t know how many

42. In the past 12 months, have you eaten waterfowl (such as ducks or geese) that were harvested in any other locations not listed/pictured here?

YES: Specify location:_________________

NO

Don’t know

Prefer not to answer

LIFESTYLE AND ACTIVITIES

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

43. The following question is about any supplements you may take.

On most days, do you take or use:	Yes	No	Don’t know	Prefer not to answer
Herbal medicine or supplements
Fish oil
Store-bought Betel nut
Natural or hand-made Betel nut

44. Do you use a homemade or store-bought yellow powder/cream called Thanakar or Thanakha?

Yes, Homemade

Yes, Store bought

No  Skip to #46

Don’t know  Skip to #46

Prefer not to answer  Skip to #46

45. How often do you use Thanakar?

_____ times per (circle one) week month year

Don’t know

Prefer not to answer

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

Yes (Ever smoker)

No (Never smoker)  Skip to #49

Don’t know  Skip to #49

Prefer not to answer  Skip to #49

47. Do you smoke cigarettes now?

Yes

No  Skip to #49

Don’t know  Skip to #49

Prefer not to answer  Skip to #49

48. 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

49. Do you use chewing tobacco or snuff?

Yes

No Skip to #51

Don’t know  Skip to #51

Prefer not to answer  Skip to #51

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

Daily

Weekly

Monthly

Don’t know

Prefer not to answer

51. Please look at this picture of lakes, rivers, and streams in the Milwaukee area. Do you swim, dive, or wade in any of these local bodies of water? (Will include map/picture of water bodies)

Yes 47a. How many times in the past year? ______

No

Don't know

Prefer not to answer

52. 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 or glazing,
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.

53. Including yourself, how many people currently live at your address?

Total number: _____________

Live alone  SKIP to #52

Don’t know  SKIP to #52

Prefer not to answer  SKIP to #52

54. How many people who live with you are women between 15 and 45 years old?

Number: _____ (If 0,  SKIP to #55)

Don’t know  SKIP to #55

Prefer not to answer  SKIP to #55

54a. Do any of these women eat locally caught fish?
Yes

No

Don’t know

Prefer not to answer

55. How many children who live with you are under the age of 15?

Number under 15 years: _____ (if 0  SKIP to #56)

Don’t know  SKIP to #56

Prefer not to answer  SKIP to #56

55a. 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.

56. 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

57. What is your current marital status?

Married

Living with someone in a marriage-like relationship

Separated

Divorced

Widowed

Never married
Prefer not to answer

58. Do you currently work outside the home?

Yes, Full-time

Yes, Part-time

No  SKIP to #59

Don’t know SKIP to #59

Prefer not to answer SKIP to #59

58a. 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? _________________________________

58b. Do you have a second job?

Yes

No  SKIP to #59

Don’t know  SKIP to #59

Prefer not to answer  SKIP to #59

58bi. What is your second job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties?_________________________________

58c. Have you worked at any (other) job in the past year?

Yes, Full-time

Yes, Part time

No  SKIP to #59

Don’t know  SKIP to #59

Prefer not to answer  SKIP to #59

58ci. What was this other job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties? ________________________________

59. Does anyone in your household receive SNAP or WIC services (such as food stamps)?

Yes

No

Don’t know

Prefer not to answer

60. 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:
61. 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
62. 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 : __________________
63. 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: _________________
64. 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	Type 1:
	Type 2:
	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
65. A thyroid condition
66. Diabetes	YES IF YES, What kind? Insulin Oral medication Both
67. High blood pressure
68. High cholesterol
69. Other health conditions

REPRODUCTIVE HISTORY – FEMALE ONLY

If male, skip to END SURVEY

These next questions will ask you about any children you have given birth to and breastfed.

70. Have you ever been pregnant?

Yes, If yes, 70a. How many times? _______

No END INTERVIEW

Don’t know END INTERVIEW

Prefer not to answer End survey

71. How many of these pregnancies resulted in a live birth?

Number of live births ______

Never

Don’t know

Prefer not to answer

72. Have you ever breastfed any children?

Yes

No END INTERVIEW

Don’t know END INTERVIEW

Prefer not to answer END INTERVIEW

72b. 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 INTERVIEW

Interviewer script:

Thank you for participating in this project. Before you leave today, we would like to know if you would be willing to invite 3 people from your community to participate in this project. Please DO NOT invite people who live in your home. We would give you 3 invitations and spend a few minutes today giving you some instructions on who to give these invitations to. The people you invite will need to bring the letter with them if they decide to participate in the project. We will give you an additional $15 gift card as a token of appreciation for each person that brings in this invitation and participates in this project like you did today.

1. Would you be willing to invite 3 people from your community to participate in this project?

NO -> thank the participant for their time and let them know they may leave.

YES -> Record serial numbers on the invitations and give them to the participant.
Coupon 1 serial number: ____________________________

Coupon 2 serial number: ____________________________

Coupon 3 serial number: ____________________________