Child Questionnaire - Short Form

Attachment 17a.

Form Approved

OMB No. 0923-XXXX

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

Exp. Date xx/xx/20xx

Pease Child Questionnaire – Short Form

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-xxxx).

(for parent/guardian who is also an adult participant; best completed by the child’s birth mother)

Adult Study ID No. |_________________| (alias)

Parent Study ID No. |_________________|

Child Study ID No. |_________________|

INSTRUCTIONS TO INTERVIEWER: Record, but do not read response options aloud for “Don’t Know” or “Refused”

Section A: Demographic Information

A1. What is your relationship to your child?

___Birth mother

___Birth father

___Adoptive mother

___Adoptive father

___Legal guardian

___Other relationship: specify ____________________________

___Refused to answer

A2. What is your child’s sex?

___Male

___Female

___Refused to answer

A3. What is your child’s age?

___(YY)

___Refused to answer

A4. Do you consider your child to be Hispanic or Latino?

___Yes

___No

___Refused to answer

A5. What race do you consider your child 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 grade level of education your child has completed?

___grade

Section B: Drinking Water and AAAF Exposures

This next set of questions is about the child and the child’s birth mother. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

B1. On average, how many 8 oz. cups of tap water or beverages prepared with tap water does your child currently drink per day at home?

___ 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.)

B2. Did your child attend day care 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.)

___Yes,

___No → go to Question B5.

___Refused to answer →go to Question B5.

___Don’t Know →go to Question B5.

B3. When did your child attend day care at the Pease International Tradeport?

Start date ___________ End date_________

____ Don’t Know ____ Don’t Know

B4. The next two questions are about drinking water habits of children 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 your child 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 your child drink per day at day care?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not attend day care at Pease 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.)

B5. During the time your child attended day care 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 your child drink per day at day care?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not attend day care at Pease 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.)

B6. When [you were/the child’s birth mother was] pregnant with your child, on average how many 8 oz. cups of tap water or beverages prepared with tap water did [you/she] drink per day?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

B7. When [you were/the child’s birth mother was] breastfeeding your child, on average how many 8 oz. cups of tap water or beverages prepared with tap water did [you/she] drink per day?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___Did not breastfeed my child

Section C: History of Potential Exposure Modifiers

This next set of questions is for the child’s birth mother about the child. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

C1. Has your child 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 your child last have a blood transfusion?

________month/year

___Follow up later

C3. Has your child ever donated blood?

___Yes

___Follow up later

___No →go to Section D.

___Don’t know →go to Section D.

___Refused to answer →go to Section D.

C4. When did your child last donate blood?

________ Month/Year

C5. On average, how often does your child donate blood in a year?

__________

Section D: Occupational History

This next set of questions is for the child’s birth mother about the child. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

D1. Has your child been employed for at least one month at a job?

____Yes

____No → go to Section E.

Job information	Job 1	Job 2	Job 3
a. Where did your child work? (City, State)
b. Was this job located at former Pease Air Force Base or the Pease International Tradeport?	Yes___ No____	Yes___ No____	Yes___ No____
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did your child work with or around radiation or any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify) _______________ No ____ Don’t know___	Yes (Please specify) ________________ No___ D Don’t know____	Yes (Please specify) _______________ No____ Don’t know____
	If Job 1.b is yes - Go to D2 If Job 1.b is no - Go to Job 2	If Job 2.b is yes - Go to D4 If Job 2.b is no - Go to Job 3	If Job 3.b is yes - Go to D6 If Job 3.b is no - Go to Section E

D2. The next two questions are about your child’s drinking water habits in Job 1 before and after the PFAS contamination was discovered and corrected. I am using June 2014 as that date. For Job 1, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

D3. For Job 1, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

D4. The next two questions are about your child’s drinking water habits in Job 2 before and after the PFAS contamination was discovered and corrected. I am using June 2014 as that date. For Job 2, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

D5. For Job 2, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

D6. The next two questions are about your child’s drinking water habits in Job 3 before and after the PFAS contamination was discovered and corrected. I am using June 2014 as that date. For Job 3, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

D7. For Job 3, during the time your child 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 [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___My child did not work at Pease 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.)

Section E: Child’s Medical History

E1. Have you ever been told by a doctor or other health care provider that your child has or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical condition
Allergies?	Yes (Please specify)__________________ No Don’t know
Atopic dermatitis/eczema?	Yes (Please specify)__________________ No Don’t know
Asthma?	Yes No Don’t know
Stuffy/runny nose?	Yes No Don’t know
High cholesterol?	Yes No Don’t know
Thyroid disease?	Yes (Please specify)__________________ No Don’t know
Delayed puberty?	Yes (Please specify) _________________ No Don’t know
Obesity?	Yes No Don’t know
Lupus	Yes No Don’t know
Celiac disease	Yes No Don’t know
Type 1 diabetes	Yes No Don’t know
Scleroderma	Yes No Don’t know
Cancer?	Yes (Please specify) ________________ No Don’t know
Attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD)?	Yes No → go to o Don’t know → go to o
Autism?	Yes No → go to p Don’t know → go to p
Other learning or behavioral problems?	Yes (Please specify) ________________ No → go to Question B2. Don’t know → go to Question B2.

E2.. What age was your child last vaccinated for:

Diphtheria, Tetanus, Pertussis (“DTaP”) age_____ Don’t know ___ never was vaccinated ____

“Tdap” booster Tetanus, Diptheria, Pertussis age_____ Don’t know ___ never was vaccinated ____

Measles, Mumps, Rubella (“MMR”) age_____ Don’t know ___ never was vaccinated ____

Tetanus shot (for a puncture wound or cut) age_____ Don’t know ___ never was vaccinated ____

FOR GIRLS ONLY

E3. Has your daughter ever used an oral contraceptive (“birth control pill”)?

___Yes

___No → go to Question E5

___Don’t know → go to Question E5

___Refused to answer → go to Question E5

E4. When did your daughter last use an oral contraceptive (“birth control pill”)?

________Month/Year

E5. At what age did your daughter begin menstruation (have her first period)?

___Age

___Has not yet begun to menstruate

___Never menstruated

___Don’t know

E6. Has your daughter ever been pregnant? ___Yes

___No → go to Section F

___Don’t Know → go to Section F

___Refused to answer → go to Section F

E7. What month and year did this pregnancy start?

_ _ / _ _ _ _ (MM/YYYY)

E8. What month and year did this pregnancy end?

_ _ / _ _ _ _ (MM/YYYY)

E9. What was the outcome of the pregnancy?

____live birth, single or multiple children

____Elective abortion, miscarriage, stillbirth, tubal pregnancy → go to Section E

E10. Did your daughter breastfeed the child?

____Yes

____No → go to Section F

E11. How long did your daughter breastfeed the child?

_______weeks OR

_______months OR

_______age of the child

Section F: Family Medical History

F1. Have any of your child’s blood relatives - 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?
Thyroid disease?	Yes (Please specify) ______________________ No Don’t know	Child Parent Sibling
Lupus?	Yes No Don’t know	Child Parent Sibling
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
Celiac disease?	Yes No Don’t know	Child Parent Sibling
Crohn’s disease?	Yes No Don’t know	Child Parent Sibling
Asthma?	Yes No Don’t know	Child Parent Sibling
Scleroderma	Yes No Don’t know	Child Parent Sibling
High Cholesterol	Yes No Don’t know	Child Parent Sibling
Allergies	Yes (Please specify)__________________ No Don’t know	Child Parent Sibling
Atopic dermatitis/eczema	Yes No Don’t know	Child Parent Sibling
Attention deficit hyperactivity disorder (ADHD or attention deficit disorder (ADD)	Yes No Don’t know	Child Parent Sibling
Autism	Yes No Don’t know	Child Parent Sibling
Other learning or behavioral problems	Yes No Don’t know	Child Parent Sibling
Obesity	Yes No Don’t know	Child Parent Sibling

Section G: History of Pease PFC Blood Testing Program

G1. Did your child participate in the Pease PFC Blood Testing Program?

___Yes

___No →go to CONCLUSION

___Don’t know

G2. Please provide your child’s 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.