0923-0048 Household Questionnaire - Adult (Robust)

Appendix C1: Household Questionnaire

Form Approved

OMB No. 0923-0048

Exp. Date 04/30/2022

Respondent ID No:

Environmental Sampling for PFAS at Selected Exposure Assessment Locations,

Household Questionnaire

ATSDR estimates the average public reporting burden for this collection of information as 15 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 (0923-0048).

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

4. 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

4. 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

4. If you used a filter or treatment device, was it maintained and replaced according to manufacturer’s recommendations? 

• Yes

• No

• Don’t know

4. 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

4. 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

4. 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

4. 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

4. 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

4. What is the approximate square footage of your home?

___________________________________

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

• Yes

• No

• Don’t know

4. 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

4. 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

4. If yes, how often? ___________________________________

4. Have you ever used a professional carpet cleaning or treatment service?

• Yes

• No

• Don’t know

4. If yes, how often? ___________________________________

4. 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

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

• Yes

• No

• Don’t know

4. If yes, how often? ____________________

Surfaces

4. 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

25. Do you have any pets that spend time both indoors and outdoors?

• Yes

• No

25. Do you have a yard?

• Yes

• No

25. 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

25. How often did you water your lawn before the PFAS was removed or mitigated from your water?

• Daily

• Weekly

• Monthly

• Never

• Don’t know

25. How often do you water your lawn after PFAS was removed or mitigated from your water?

• Daily

• Weekly

• Monthly

• Never

• Don’t know