Att14_ApxC1_Household Quest _ FINAL

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Appendix C1: Household Questionnaire






Environmental Sampling for PFAS at Selected Exposure Assessment Locations, 
Household Questionnaire 

 




Thank you for participating in the environmental sampling EI.
This household questionnaire should be completed by an adult in the household that:
    • Provided a blood sample during the Exposure Assessment
    • Completed and signed Adult Consent Form 1 (Environmental Sampling and Questionnaire) 
ATSDR will pick up this form from you when we come to your home for the environmental sampling.

Demographics

Name : ___________________________________________________  
Date of Birth: _________ (Month/Day/Year)	
Address: _________________________________________________

Residence 

    1. Do you still live in the home you lived in when you were tested during the Exposure Assessment (date of EA)?   ­­

    • ­Yes 

    • No
    2. What is your annual household income? 

____________________________________________________

    • Don’t know 
    • Prefer not to answer 

    3. What was your annual household income during the Exposure Assessment [insert year of EA for each site here]?
_____________________________________________________
    • Don’t know 
    • Prefer not to answer 


Water

    4. What was the main source of drinking water in your home prior to [the date the PFAS in the water was mitigated]? 
        ◦ Municipal water directly from the tap		
            ▪ If yes, what is the name of the public water system you were served by? 
________________________________________________________

        ◦ Municipal water directly from the tap – filtered
            ▪ If yes, what is the name of the public water system you were served by? 
________________________________________________________

        ◦ Bottled water 
        ◦ Other


    5. Prior to the PFAS being mitigated from your water on [insert specific date], which, if any, water filter or treatment device did you use to filter or treat the tap water you drink? (select all that apply)  	 


    • Under the sink carbon filter or treatment device
    • Other, specify: _______________________ 	
    • Faucet filter or treatment device
    • Don’t Know
    • Pitcher filter  
    • Refused to answer            
    • Refrigerator filter
    • Not Applicable

    • None, use bottled water only
    • None, no filter or treatment device used         

    6. If you used a filter or treatment device, when did you start filtration (mm/dd/yyyy)?  
    • Yes
        ◦ If yes, what date? __________________
    • No 
    • Don’t know

    7. If you used a filter or treatment device, was it maintained and replaced according to manufacturer’s recommendations? 
    • Yes
    • No 
    • Don’t know


    8. After the PFAS was removed or mitigated (date of mitigation), what was your main source of drinking water in your home?
        ◦ Municipal water directly from the tap
        ◦ Municipal water directly from the tap – filtered
        ◦ Bottled water
        ◦ Other

    9. After the PFAS was removed or mitigated [insert specific date], which, if any, water filter or treatment device do you use to filter or treat the tap water you drink? (select all that apply)  	 

    • Whole house carbon filter		
    • Reverse osmosis (RO) system 
    • Under the sink carbon filter 
    • Other, specify: _______________________ 	
    • Faucet filter
    • Don’t Know
    • Pitcher filter  
    • Refused to answer            
    • Refrigerator filter
    • Not Applicable
    • None, use bottled water only
    • None, no filter, or treatment device used         

    10. If you began using a filter after the PFAS was removed or mitigated, when did you start filtration (mm/dd/yyyy)?  

    • Yes
        ◦ If yes, what date? __________________
    • No 
    • Don’t know


    11. Was the filter or treatment device you used after the PFAS was removed or mitigated from your water maintained and replaced according to manufacturer’s recommendations? 
    • Yes
    • No 
    • Don’t know

    12. Which, if any, water filter or treatment device are you currently using to filter or treat household water for exterior use? (e.g., gardening) (select all that apply)  	 

    • 
    • Whole house carbon filter 
    • 
    • Reverse osmosis (RO) system 
    • Other, specify: ____________________

    • Don’t Know

    • Refused to answer            

    • Not Applicable

    • None, no filter or treatment device used


Housing Characteristics
Flooring 

    13. What is the approximate square footage of your home? 
___________________________________

    14. Do you generally leave windows open in your home? 

    • Yes
    • No
    • Don’t know

    15. What type(s) of flooring do you have in the following rooms? When was it installed?

Room
Hardwood
Tile
Laminate
Carpet
Vinyl
Other
Don’t know 
Living Room







Bedrooms







Kitchen







Bathroom







Other








    16. If you have carpet or rugs in your home, have you ever treated that carpet/rug with stain-resistant products?
    • Yes 
    • No
    • Don’t know


    17. If yes, how often? ___________________________________

    18. Have you ever used a professional carpet cleaning or treatment service?
    • Yes
    • No
    • Don’t know

    19. If yes, how often? ___________________________________


    20. Do you have any furniture (couch, etc.) or carpeting/rugs in your house that were pre-treated with stain-resistant products?

    • Yes
    •  No
    • Don’t know 
	

    21. Do you have upholstered furniture that you treat with stain-resistant products?

    • Yes
    •  No
    • Don’t know 

    22. If yes, how often? ____________________

Surfaces
    23. How often do you dust or wipe down surfaces in your home, including windowsills? 
    • Daily
    • Weekly
    • Monthly
    • Seasonally
    • Never
    • Don’t know

24. How often do you clean the floors in your room (e.g., sweep, mop, vacuum)?

Room
Everyday
A few times a week
A few times per month
A few times a year
Never
Don’t know
Preferred not to answer 
Living Room







Bedrooms







Kitchen







Bathrooms







Other

















Consumer Products

    25. Do you currently use any of the following products in your home? (Check box) 

Product type
No
Yes – use them occasionally (monthly)
Yes – use them often (daily or weekly)
Food contact materials
Paper products (plates, cups)



Fast food clamshells (paper)



Fast food containers (paper, cardboard)



Cupcake or muffin paper cups



Food contact paper (parchment paper)







Apparel/clothing/gear
Waterproof shoes



Water resistant jackets or coats



Stain resistant products (clothing)



Outdoor gear - tent



Waterproofing treatment for apparel (shoe, textile, and leather)



Surface treatment products
Floor wax, sealants, or polish



Kitchen counter sealant



Furniture polish



Boat, Car, Ski wax



Lubricants (bicycles, etc.)



Car detailing products



    26. Do you have any pets that spend time both indoors and outdoors? 
    • Yes
    • No
    27. Do you have a yard?
    • Yes 
    • No
    28. Do you have your lawn treated or do you treat your lawn with treatment products (fertilizers, weed or insect treatment)?  
    • Yes
    • No
    • Don’t know 
    29. How often did you water your lawn before the PFAS was removed or mitigated from your water?
    • Daily
    • Weekly
    • Monthly
    • Never
    • Don’t know
    30. How often do you water your lawn after PFAS was removed or mitigated from your water?
    • Daily
    • Weekly
    • Monthly
    • Never
    • Don’t know