0923-0048 Personal Exposure Questionnaire - Adult Consent (Self On

Appendix C2: Personal Exposure Questionnaire (Adult)

Form Approved

OMB No. 0923-0048

Exp. Date 04/30/2022

Environmental Sampling for PFAS at Selected Exposure Assessment Locations

Personal Exposure Questionnaire (Adult)

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 personal exposure questionnaire should be completed by every adult in the household that:

• Provided a blood sample during the Exposure Assessment

• Completed and signed an Adult Consent Form 1 (Sampling and Questionnaire) or Adult Consent Form 2 (Questionnaire only)

ATSDR will pick up this form from you when we come to your home for the environmental sampling.

These questions will be asked for every adult in the household.

Demographics

Name : ___________________________________________________

Date of Birth: _________ (Month/Day/Year)

Address: _________________________________________________

1. Since the exposure assessment, do you work in any of the following industries? (select all that apply)

• Manufacturing of nonstick cookware

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

• Manufacturing of leather products

• Manufacturing of water-resistant clothing

• Manufacturing of aqueous film forming foam (AFFF)

• Manufacturing/Processing/Formulating facility of PFAS chemicals

• Military

• Aviation

• Firefighting

• Never worked in the industries listed above

• Prefer not to answer

Water

2. Prior to PFAS being mitigated/removed from your water on (date of mitigation), on average, how many 8-oz cups of tap water or beverages/soups prepared with tap water did you drink while at home per day?

____ (8-oz cups)

• Didn’t drink tap water

• Don’t know

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

3. After PFAS were mitigated from your water (date of mitigation), how many 8-oz cups of water or beverages prepared with tap water do you drink while at home per day?

____ (8-oz cups)

• Didn’t drink tap water

• Don’t know

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

Soil

4. How frequently do you come into direct contact with the soil (e.g. gardening, digging, home improvement, etc. at your home (select one)?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

5. Do you usually remove your shoes when you enter the home?

• Yes

• No

6. Before the pandemic (January 2020), how much time did you spend outdoors on a typical work/school/daycare day?

   • Never

   • 1-4 hours

   • 4-8 hours

   • Over 8 hours

   • Don’t know

7. During/after the pandemic, how much time do you spend outdoors on a typical non-work/school/daycare day?

   • Never

   • 1-4 hours

   • 4-8 hours

   • Over 8 hours

   • Don’t know

Diet

8. Do you eat locally grown vegetables or fruits from [insert affected area/sampling frame/locations – show map of sampling frame to participant]?

• Yes 

• No  

• Don’t Know  

If yes, what time of year do you buy local produce? Please check all that apply.

• Fall

• Winter

• Spring

• Summer

 

If yes, how often do you eat locally grown fruits or vegetables when in season? (select one) 

• Every day  

• A few times per week

• A few times per month

• Rarely  

• Never  

• Don’t know  

 

If yes, where do you buy these locally grown fruits or vegetables? 

• Farmer’s market  

• Local grocery store 

• Vegetable / fruit stand 

• Produce box or other home delivery service

• Don’t know

9. Do you eat vegetables or fruits grown at your home?

• Yes 

• No  

• Don’t Know  

If yes, how often do you eat fruits or vegetables grown at your home? (select one) 

• Every day  

• Once per week  

• Once per month  

• A few times per year  

• Rarely  

• Never  

• Don’t know  

If yes, what time of year do you grow vegetables or fruits at your home? Please check all that apply.

• Fall

• Winter

• Spring

• Summer

If yes, what is the source of the water for your homegrown produce? 

• Outside hose

• Tap water from inside the house

• Bottled water

• Rain barrel

• Other

• Don’t know

10. Do you eat fish locally caught from ponds, lakes, streams, or rivers in [insert affected area/sampling frame/locations – can show map of sampling area]? 

• Yes 

• No  

• Don’t Know  

 

If yes, how often do you eat locally caught fish (select one)? 

• 3 times per week or more  

• A few times per month  

• A few times per year  

• Rarely

• Don’t know  

11. Do you consume fish from the grocery store?

• Yes 

• No  

• Don’t Know  

If yes, how often do you consume fish from the grocery store?

• Every day  

• A few times per week

• A few times per month

• A few times per year  

• Rarely   

  • Don’t know  

12. Do you consume fast food or convenience type of foods (can give an example)?

• Yes 

• No  

• Don’t Know  

If yes, how often do you consume fast food? 

• Every day  

• Once per week  

• Once per month  

• A few times per year  

• Rarely  

  • Never  

  • Don’t know  

If yes, what type of fast food or convenience food products do you generally consume and how often do you consume it?

	How often the fast food or convenience type of food is eaten
	Daily	Once/week	Once/month	Few times/year	Never	Don’t know	Prefer not to answer
Food name
French fries
Take-out pizza (in a box with a separate liner)
Frozen pizza (in a box with a separate liner)
Burgers or sandwiches wrapped in paper
Burgers or sandwiches in cardboard box (fast food paper clamshells)
Frozen convenience meals (in cardboard)
Microwave popcorn

 

13. 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)
Personal care products
Waxed dental floss and plaque removers
Nail polish
Tooth whitening products
Makeup products
Hair styling products (shampoo and conditioner)

14. Is there anything else you want to tell us about your PFAS exposures?

____________________________________________________________________________

*** THANK YOU ***