Adult Questionnaire

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

P_Att18_PeaseAdltQstnnr_20180802

Adult Questionnaire

OMB: 0923-0061

Document [docx]
Download: docx | pdf

Attachment 18.

Shape1

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx




Shape2

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-xxxx).

Pease Adult Questionnaire

Parent Study ID No. |_________________| (alias, if applicable)

Adult Study ID No. |_________________|



Section A: Demographic Information



A1. What is your sex:

___Male

___Female

___Refused to answer



A2. What is your date of age?

___(YY)

___Refused to answer



A3. Do you consider yourself to be Hispanic or Latino?

___Yes

___No

___Refused to answer



A4. What race do you consider yourself to be? Mark all that apply.

___American Indian or Alaska Native

___Asian

___Black or African American

___Native Hawaiian or Other Pacific Islander

___White

___Refused to answer


A6. What is the highest level of education you completed?

___Less than high school

___Some high school

___High school graduate or equivalent (GED)

___Some university/college

___Technical or trade school

___University/college graduate

___Graduate school or higher




Section B: Drinking Water and AAAF Exposures



B1. What is the main source of tap water in your home?

____Pease International Tradeport public water system

____Other Portsmouth public water system

____Private well in Pease International Tradeport area with documented PFAS contamination

____Private well not in Pease International Tradeport area

____Other: specify ____________________________________

____Don’t know

____Refused to answer



B2. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at home?

___ cups

___Don’t drink tap water

___Don’t know

___Refused to answer


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)



B3. Were you ever stationed or employed at the former Pease Air Force Base?

___Yes, stationed only, active duty → go to Question B4

___Yes, both stationed and employed → go to Question B4

___Yes, employed only, not active duty → go to Question B5

___No → go to Question B10



B4. When were you stationed at the former Pease Air Force Base?

Starting Date: _ _ / _ _ _ _(Month/Year) End Date: _ _ / _ _ _ _(Month/Year)

____ Don’t Know ____ Don’t Know


If B3 = Yes, stationed only, active duty → go to Question B6



B5. When were you employed at the former Pease Air Force Base?

Starting Date: _ _ / _ _ _ _(Month/Year) End Date: _ _ / _ _ _ _(Month/Year)

____ Don’t Know ____ Don’t Know



B6. While at the former Pease Air Force Base, did you take part in firefighting training exercises or was fire protection your occupational specialty (or enlisted job)?

___Yes _______Training _________Occupational specialty

___No



B7. During the time you were stationed or employed at the former Pease Air Force Base, on average how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day while on base?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)


While at the former Pease Air Force Base, did you take part in firefighting training exercises or was fire protection your occupational specialty (or enlisted job)



B8. Did you ever work at the Pease International Tradeport in Portsmouth, New Hampshire?

___Yes

___No →go to Question B11.



B9. When were you employed at the Pease International Tradeport?

Starting Date: _ _ / _ _ _ _(Month/Year) End Date: _ _ / _ _ _ _(Month/Year)

____ Don’t Know ____ Don’t Know



B10. The next two questions are about drinking water habits of people who worked at the Pease International Tradeport before and after the PFAS contamination was discovered and corrected. I am using June 2014 as that date. During the time you worked at the Pease International Tradeport before June 2014, on average how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___I did not work at the Pease International Tradeport before June 2014


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)



B11. During the time you worked at the Pease International Tradeport after June 2014, on average how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___I did not work at the Pease International Tradeport after June 2014


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)



B12. If you are 35 years of age or younger, did you ever attended daycare at the Pease International Tradeport? (The day care centers at the Pease International Tradeport are The Discovery Child Enrichment Center and The Great Bay Kids’ Company.)

___I am older than 35 years of age →go to Question C1.

___Yes, I attended day care at Pease

___No → go to Question C1.

___Refused to answer →go to Question C1.

___Don’t Know →go to Question C1.



B13. When did you attend day care at the Pease International Tradeport?

Start date ___________ End date_________

____ Don’t Know ____ Don’t Know



B14. The next two questions are about drinking water habits of people who attended day care at the Pease International Tradeport before and after the PFAS contamination was discovered and corrected. I am using June 2014 as that date. During the time you attended day care at the Pease International Tradeport before June 2014, on average how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day at day care?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___I did not attend day care at the Pease International Tradeport before June 2014


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)



B15. During the time you attended day care at the Pease International Tradeport before June 2014, on average how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day at day care?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___I did not attend day care at the Pease International Tradeport before June 2014


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)



Section C: History of Potential Exposure Modifiers



C1. Have you ever had a blood transfusion?

___Yes

___Follow up later

___No →go to Question C3

___Don’t know →go to Question C3

___Refused to answer →go to Question C3



C2. When did you last have a blood transfusion?

________month/year



C3. Have you ever donated blood?

___Yes

___No →go to Question D1

___Don’t know →go to Question D1

___Refused to answer →go to Question D1



C4. When did you last donate blood?

________ Month/Year



C5. On average, how often do you donate blood in a year?

__________




Section D: Occupational History


D1. What is your primary occupation?

_______________________________________


D2. Please fill out the table below for each job that lasted one month or more starting from the present and working back to 1993.



Job information

Job 1

Job 2

Job 3

Job 4

a. Where did you work (City, State)





b. Was this job located at the former Pease Air Force Base or the Pease International Tradeport?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____

c. Start date (month, year)





d. End date (month, year)





e. Job title/description





f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D Don’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____


Job information

Job 5

Job 6

Job 7

Job 8

a. Where did you work (City, State)





b. Was this job located at the former Pease Air Force Base or the Pease

International Tradeport?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____

c. Start date (month, year)





d. End date (month, year)





e. Job title/description





f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D Don’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____


Job information

Job 9

Job 10

Job 11

Job 12

a. Where did you work (City, State)





b. Was this job located at the former Pease Air Force Base or the Pease International Tradeport?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____

c. Start date (month, year)





d. End date (month, year)





e. Job title/description





f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D Don’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____



Section E: Medical History



E1. Have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? If yes, we may request access to your medical records. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.


Medical condition


If yes, what year were you diagnosed?

  1. Thyroid disease?

Yes (Please specify) ______________________

No

Don’t know

_ _ _ _ year

  1. High cholesterol?

Yes

No

Don’t know

_ _ _ _ year

  1. High blood pressure? (not including pregnancy induced hypertension)

Yes

No

Don’t know

_ _ _ _ year

  1. Heart Disease?

Yes

No

Don’t know

_ _ _ _ year

  1. Osteoarthritis or osteoporosis?


Yes (Please specify) ______________________

No

Don’t know

_ _ _ _ year

  1. Endometriosis?

Yes

No

Don’t know

_ _ _ _ year

  1. Liver disease?

Yes (Please specify) ______________________

No

Don’t know

_ _ _ _ year

  1. Kidney disease?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Ulcerative colitis?

Yes

No

Don’t know

_ _ _ _ year

  1. Rheumatoid arthritis?

Yes

No

Don’t know

_ _ _ _ year

  1. Lupus?

Yes

No

Don’t know

_ _ _ _ year

  1. Multiple sclerosis?

Yes

No

Don’t know

_ _ _ _ year

  1. Diabetes (not related to pregnancy)?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Asthma

Yes

No

Don’t know

_ _ _ _ year

  1. Parkinson Disease

Yes

No

Don’t know

_ _ _ _ year

  1. Chronic bronchitis

Yes

No

Don’t know

_ _ _ _ year

  1. Emphysema

Yes

No

Don’t know

_ _ _ _ year

  1. Fibromyalgia

Yes

No

Don’t know

_ _ _ _ year

  1. Celiac Disease

Yes

No

Don’t know

_ _ _ _ year

  1. Crohn’s Disease

Yes

No

Don’t know

_ _ _ _ year



E2. Have you ever been told by a doctor or other health care provider that you have or had a cancer?

____Yes, please specify the cancer_______________

____No → go to Question D6

____Don’t know → go to Question D6



E3. In what state were you diagnosed with the cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed



E4. Have you been diagnosed with another cancer?

____Yes, please specify the cancer_______________

____No → go to Question D6



E5. In what state were you diagnosed with the other cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed



E6. Please list any additional cancer that you were diagnosed with, the year that you were diagnosed, and the state where you were diagnosed:

__________Type of cancer ____________Type of cancer

__________Year diagnosed ___________Year diagnosed

__________State where you were diagnosed ____________State where you were diagnosed






FOR WOMEN ONLY




E8. At what age did you begin menstruation (have your first period)?

___Age when you began menstruation

___Have not yet begun to menstruate → go to Section F

___Never menstruated → go to Section F

___Don’t know



E9. Do you have your period

___Yes, regularly (every month)

___Irregular → go to Question E13

___No → go to Question E13

___Don’t know → go to Question E13



E10. How many days has been your cycle on average during the last year?

___>26 days

___27-29 days

___30-32

___>32 days

___Don’t know



E11. Can you characterize you usual period flow during the last year?

___Light

___Medium

___Heavy

___Don’t know



E12. When was your last period before this study blood draw?

Date:______________

___Don’t know



E13. Are you post-menopausal?

___Yes

___No → go to Question E15

___Don’t know



E14. What age did you consider yourself post-menopausal?

___ years



E15. Have you ever been pregnant?

___Yes

___No → go to Section F

___Don’t know



E16. How many times have you been pregnant in your life?

_______ times



E17. Now I’d like to get more information about each of your pregnancies. Let’s start with your most recent pregnancy. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.


Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

a. What month and year did this pregnancy start?

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

b. What month and year did this pregnancy end?

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _


Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

c. What was the outcome of this pregnancy?

Live birth, single child

Live birth, multiple children

Tubal pregnancy

Elective abortion

Miscarriage or stillbirth

Live birth, single child

Live birth, multiple children

Tubal pregnancy

Elective abortion

Miscarriage or stillbirth

Live birth, single child

Live birth, multiple children

Tubal pregnancy

Elective abortion

Miscarriage or stillbirth

Live birth, single child

Live birth, multiple children

Tubal pregnancy

Elective abortion

Miscarriage or stillbirth

d. If you had a miscarriage or stillbirth, how many weeks were you when the pregnancy

ended?


go to Part k or to Section F if last pregnancy


___weeks


___weeks


___weeks


___weeks

e. What was the sex of the child(ren)?

Male

Female

Male

Female

Male

Female

Male

Female

f. Did the birth(s) occur three or more weeks before the due date?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

g. Did the child(ren) weigh less

than 5.5 pounds when born?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

h. Did the child(ren) have any major birth defects?

Yes (Please specify) _________________

No

Don’t know

Yes (Please specify) _________________

No

Don’t know

Yes (Please specify) _________________

No

Don’t know

Yes (Please specify) _________________

No

Don’t know

i. Did you breastfed this child/these children?

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

j. How long did you breastfeed [this child/these children]?

_ _ weeks OR

_ _ months OR

_ _ age of child

_ _ weeks OR

_ _ months OR

_ _ age of child

_ _ weeks OR

_ _ months OR

_ _ age of child

_ _ weeks OR

_ _ months OR

_ _ age of child


Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

k. Did a doctor or nurse say that you had pre-eclampsia during your

pregnancy?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

l. Did a doctor or nurse say that you had pregnancy-induced hypertension?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

m. Did a doctor or nurse say that you had gestational diabetes?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know



Section F: Social History


The following questions ask about smoking and alcohol use.


F1. Have you ever smoked cigarettes?

___Yes

___No → go to Question F7



F2. Do you currently smoke cigarettes?

___Yes

___No → go to Question F5



F3. On average, how many cigarettes do you smoke a day? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day



F4. In total, how many years have you smoked, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Question F7




F5. How many years did you smoke before you quit?

___years

___ Don’t know




F6. On average, when you were smoking, about how many cigarettes per day did you smoke? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day




F7. Have you ever used any other tobacco products (such as chewing tobacco, smokeless tobacco, cigars, a pipe, etc.)?

___Yes

___No → go to Question F10




F8. Do you currently use any of these tobacco products?

___Yes

___No




F9. Have you ever drunk alcoholic beverages? (This includes beer, wine, wine coolers, hard

lemonade, and spirits.)

___Yes

___No → go to Section G




F10. Do you currently drink alcoholic beverages? (This includes beer, wine, wine coolers, hard lemonade, and spirits.)

___Yes

___No → go to Section G.




F11. On average, how often do you drink alcoholic beverages?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month




F12. When you drink, how many servings of alcohol do you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings




F13. In total, how many years have you drank, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Section G



F14. When you were consuming alcoholic beverages, how often did you drink on average?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month




F15. When you drank, how many servings of alcohol did you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings




F16. In total, how many years did you drink? Enter ‘00’ if less than 1 year.

____ years




F17. How long ago did you quit?

___Less than 5 years ago

___More than 5 years ago

___Don’t know




Section G: Family Medical History

G1. Do any of your blood relatives - children, parents, or siblings - currently have cancer or have they had cancer? We are only asking about family members who are blood relatives: children, parents, and siblings.

___Yes

___No → go to Question G4


G2. In all, how many family members (not including yourself) have had (or now have) cancer?

___number

___Don’t know


G3. Now I’d like to get more information about each of your relatives who had/has cancer. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Complete the information for the first relative completely before asking about the next relative. Once information about all blood relatives with cancer has been collected, go to Question G4.



First relative

Second relative

Third relative

Fourth relative

a. Was this relative a . . .

Child

Parent

Sibling

Child

Parent

Sibling

Child

Parent

Sibling

Child

Parent

Sibling

b. What type of cancer did this relative have













c. Is this relative

Living

Deceased

Living

Deceased

Living

Deceased

Living

Deceased

d. What year was your relative diagnosed with cancer?


_ _ _ _

Don’t know


_ _ _ _

Don’t know


_ _ _ _

Don’t know


_ _ _ _

Don’t know


G4. Have any of your blood relatives (that is children, parents, or siblings) ever been told by a health professional that they have or had any of the following conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.


Medical condition


If yes, ask: Which relative had this condition?

  1. Thyroid disease?

Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Heart Disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Osteoarthritis?


Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Osteopenia or osteoporosis?

Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Liver disease?

Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Kidney disease?

Yes (Please specify) _____________________

No

Don’t know

Child

Parent

Sibling

  1. Ulcerative colitis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Rheumatoid arthritis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Lupus?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Multiple sclerosis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Diabetes (not related to pregnancy)?

Yes, Type 1 or juvenile

Yes, Type 2 or adult-onset

Yes, type unknown

No

Don’t know

Child

Parent

Sibling

  1. Gestationsl diabetes?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Celiac disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Crohn’s disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Fibromyalgia?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Parkinson disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Asthma?

Yes

No

Don’t know

Child

Parent

Sibling

  1. High cholesterol?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Hypertension? (not including pregnancy induced hypertension)

Yes

No

Don’t know

Child

Parent

Sibling

  1. Pregnancy induced hypertension?

Yes

No

Don’t know

Child

Parent

Sibling



Section H: History of Pease PFC Blood Testing Program


H1. Did you participate in the Pease PFC Blood Testing Program?

___Yes

___No →go to CONCLUSION.

___Don’t know →go



H2. Please provide your results (µg/L):

______PFOS

______PFOA

______PFHxS

______PFNA

______PFDeA

______PFUA

______PFOSA

______Me-PFOSA-AcOH

______Et-PFOSA-AcOH

______PFBS

______PFDoA

______PFHpA




CONCLUSION: That completes this survey. I would like to sincerely thank you for your time.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBove, Frank J. (ATSDR/DTHHS/EEB)
File Modified0000-00-00
File Created2021-01-15

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