Exposure Assessment Child

Respondent ID No:

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx201x

PFAS Exposure Assessment, ADULT (≥ 18 years of age) Questionnaire

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).

Note: Questionnaire will be administered by Exposure Assessment staff.

Script: Hello. As a part of the PFAS Exposure Assessment, I’m going to ask you some questions to learn about things that might impact your exposure to PFAS. Before I do so, I want to tell you about why we are collecting this information, and how we will protect your privacy. The statement I’m about to read you is required by the Privacy Act of 1974.

Note: The Privacy Act Statement below will be read to the participants and they will be provided a hard copy (see Appendix B of protocol).

“PRIVACY ACT STATEMENT:

ATSDR has the authority under Section 8006 of the Consolidated Appropriations Act of 2018 and the ‘‘Comprehensive Environmental Response, Compensation, and Liability Act of 1980’’ (CERCLA) as amended by ‘‘Superfund Amendments and Reauthorization Act of 1986’’ (SARA) to collect this information from you. We are conducting this assessment to evaluate your exposure to per- and polyfluoroalkyl substances, also called PFAS. ATSDR is collecting information from you to learn more about things that might impact your exposure to PFAS, and so that we can send your results back to you. ATSDR will share these records with the National Center for Environmental Health (NCEH), who may provide research or support staff and laboratory or statistical analysis. ATSDR may also disclose these records to its contractors in order to locate individuals who have been exposed to PFAS and to conduct interviews and other research activities. The contractor must comply with the requirements of the Privacy Act to protect your records. Providing this information is voluntary. ATSDR needs this information for you to take part in the assessment. ATSDR may not include incomplete records in the data analysis. ATSDR needs up-to-date contact information to send you your results.”

Now I’m going to ask you some questions. Answering these questions and collecting your blood and urine should take about 30 minutes.

Name (last name, first name) : ___________________________________________________

Date of Birth: _________ (Month/Day/Year) Sex: Male Female

Address: _________________________________________________

Height (inches): __________ Weight (pounds): ____________

1. Do you consider yourself to be Hispanic, Latino, or of Spanish origin?

• Yes

• No

2. Which one or more of the following would you say is your race? (select all that apply)

American Indian or Alaska Native	Asian	Black or African American
Native Hawaiian or Other Pacific Islander	White

3. How long have you lived at your current address? ­­

• ­__________ (months) __________ (years)

• Don’t Know

• Refused to Answer

4. Is this your full-time residence?

• Yes

• No

If No, how much time do you reside at this address?

___ Days per week ___ Weeks per month ___ Months per year □ Not Applicable

• Don’t know

• Refused to answer

4. Please list the places you have lived for the last 20 years:

Location (City, State)	Dates (MM/YYYY) of Residence

4. Has your doctor ever told you that you have:

Kidney Disease

Yes

No

Don’t Know

Refused to Answer

Questions 7 – 8 are for adult (≥18 years) females only.

4. Do you have any biological children?

• Yes

If Yes, how many? ____

• No

• Don’t Know

• Refused to Answer

4. Have you ever breastfed?

• Yes

If Yes, for how long (total for all children)? ______ (months)

• No

• Don’t Know

• Refused to Answer

4. How frequently do you donate blood and/or plasma (select one)?

Once every eight weeks

A few times per year

Once per year

Rarely

Never

Don’t Know

Refused to Answer

4. What is your current main source of drinking water in your home? (select one)

• Public water system (City or County) Provide name: __________________________

• Private Well

• Community well

• Bottled Water

• Don’t Know

• Refused to answer

4. If you have a private well, has it been tested for PFAS?

• Yes

• No

• Don’t Know

• Refused to Answer

If yes, do you know the date it was tested, who did the testing, and the results of the PFAS testing?

Date (month/year)	Company/Government	PFAS Results

4. During the time you lived in a home served by the water source identified above, on average how many 8-oz cups of water or beverages prepared with tap water did you drink while at home per day?

____ (8-oz 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)

4. Which, if any, water filter or treatment device(s) are you currently using 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. How often is your home cleaned (e.g. sweep, mop, vacuum)?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. How frequently do you apply stain resistant products (i.e. Scotchguard – sometimes applied to carpeting or upholstered furniture) in your home?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. What type of flooring do you have in your living room?

Hardwood

Tile

Laminate

Carpet

Vinyl

Other

4. What type of flooring do you have in your kitchen?

Hardwood

Tile

Laminate

Carpet

Vinyl

Other

4. What type of flooring do you have in your bedrooms?

Hardwood

Tile

Laminate

Carpet

Vinyl

Other

4. How frequently do you come into direct contact with the soil (e.g. gardening, digging, farming, building, repairing, etc…) in [insert affected area/sampling frame/locations] (select one)?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. If you come into direct contact with soil, at what address or place (e.g. daycare) does this occur (list all locations)? If you come into contact with soil at more than one location, what percentage of your total contact with soil happens at each location (percentages should sum to 100%)?

______________________________________________________________________________

______________________________________________________________________________

• Don’t know

• Refused to answer

• Not Applicable

4. Do you eat vegetables or fruits grown at your home or other locally grown vegetables or fruits from [insert affected area/sampling frame/locations]?

• Yes

• No

• Don’t Know

• Refused to Answer

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

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. Do you eat fish locally caught from ponds, lakes or rivers in [insert affected area/sampling frame/locations]?

• Yes

• No

• Don’t Know

• Refused to Answer

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

• Never

• Don’t know

• Refused to Answer

4. How often you consume milk from animals raised on farms within [insert affected area/sampling frame/locations]?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. How often you consume fast food?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

4. Please select any changes that have occurred in the last 12 months:

• My drinking water source changed from private well to public water system.

• My drinking water source changed from private well to bottled water.

• My drinking water source changed from public water system to bottled water.

• I have installed a filtration system on my private well.

• My drinking water source changed in some other way (please explain):
  
  

________________________________________________________________

• My consumption of locally caught fish has increased.

• My consumption of locally caught fish has decreased.

• My consumption of locally grown vegetables has increased.

• My consumption of locally grown vegetables has decreased.

• Other behaviors related to PFAS exposure (please explain):

_____________________________________________________________

• Refused to Answer

4. Please list your job title and where you have worked for the past 20 years. Please also identify the main source of drinking water used at each workplace (public water, private well, community well, bottled water), if known.

• Not Applicable

• Refused to Answer

Company Name	Workplace location	Job Title	Year Started	Year Ended	Drinking Water Source

4. During the time you worked, on average how many 8-oz cups of tap water or beverages prepared with tap water did you drink while at work per day?

• ____ (8-oz cups)

• Didn’t drink tap water

• Not applicable

• 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)

4. Did you in the last 20 years work in any of the following industries? (select all that apply)

• Manufacturing of nonstick cookware such as Teflon® coated pots/pans

• Manufacturing of stain resistant coatings (e.g. Scotchguard®) used on carpets, upholstery, and other fabrics

• Manufacturing of water resistant clothing (e.g. Gore-Tex®)

• Manufacturing of aqueous film forming foam (AFFF)

• Manufacturing/Processing/Formulating facility of PFAS chemicals (3M, DuPont, Chemours, etc)

• Military

• Aviation

• Firefighting

• Never worked in the industries listed above

• Refused to answer

4. If you worked in any of the industries listed in question 28, worked in the production of any of the consumer products listed in Table 1 (below), worked with PFAS-containing substances as described in Table 1 under the header “Industrial Uses,” please provide your job title, brief job description, and duration of your work.

Job Title	Job Description	Years Worked

4. Have you ever had your blood tested for any PFAS?

• Yes

• No

• Don’t Know

If yes, when, where, and what was the result?

Date of PFAS Test	Who conducted test?	Results

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

____________________________________________________________________________

Table 1. Common Uses of PFAS
Consumer Products	Industrial Uses
Cookware (Teflon®, Nonstick)	Photo-Imaging
Fast Food Containers	Metal Plating
Candy Wrappers	Semiconductor Coatings
Microwave Popcorn Bags	Aviation Hydraulic Fluids
Personal Care Products (Shampoo, Dental Floss)	Medical Devices
Cosmetics (Nail Polish, Eye Makeup)	Fire-Fighting Foam
Paints and Varnishes	Insect Baits
Stain Resistant Carpet	Printer and Copy Machine Parts
Stain Resistant Chemicals (Scotchguard®)	Chemically Driven Oil Production
Water Resistant Apparel (Gore-Tex®)	Textiles, Upholstery, Apparel and Carpets
Cleaning Products	Paper and Packaging
Electronics	Rubber and Plastics

*** THANK YOU ***

Respondent ID No:

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).

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx201x

PFAS Exposure Assessment, Child (<18 years or age of majority) Questionnaire

Note: Questionnaire will be administered by Exposure Assessment staff to the child. However, a parent or legal guardian can help answer all questions on behalf of the child. In particular, the parent or legal guardian may be asked to assist in completion of questions related to infant feeding history and places of residence.

Script: Hello. As a part of the PFAS Exposure Assessment, I’m going to ask you some questions to learn about things that might impact your exposure to PFAS. Before I do so, I want to tell you about why we are collecting this information, and how we will protect your privacy. The statement I’m about to read you is required by the Privacy Act of 1974.

Note: The Privacy Act Statement below will be read to the participants and they will be provided a hard copy. Privacy Act Statement is available in Appendix B.

“PRIVACY ACT STATEMENT:

ATSDR has the authority under Section 8006 of the Consolidated Appropriations Act of 2018 and the ‘‘Comprehensive Environmental Response, Compensation, and Liability Act of 1980’’ (CERCLA) as amended by ‘‘Superfund Amendments and Reauthorization Act of 1986’’ (SARA) to collect this information from you. We are conducting this assessment to evaluate your exposure to per- and polyfluoroalkyl substances, also called PFAS. ATSDR is collecting information from you to learn more about things that might impact your exposure to PFAS, and so that we can send your results back to you. ATSDR will share these records with the National Center for Environmental Health (NCEH), who may provide research or support staff and laboratory or statistical analysis. ATSDR may also disclose these records to its contractors in order to locate individuals who have been exposed to PFAS and to conduct interviews and other research activities. The contractor must comply with the requirements of the Privacy Act to protect your records. Providing this information is voluntary. ATSDR needs this information for you to take part in the assessment. ATSDR may not include incomplete records in the data analysis. ATSDR needs up-to-date contact information to send you your results.”

Now I’m going to ask you some questions. Answering these questions and collecting your blood and urine should take about 30 minutes.

Child’s Name: ___________________________________________________

Child’s Date of Birth: _________ (Month/Day/Year) Sex: Male Female

Address: _________________________________________________

Height (inches): __________ Weight (pounds): ____________

1. What is your birth order (e.g. first, second, or third born etc.)?

_______________

• Don’t know

• Refused to answer

2. Do you consider yourself to be Hispanic, Latino, or of Spanish origin?

• Yes

• No

3. Which one or more of the following would you say is your race? (select all that apply)

American Indian or Alaska Native	Asian	Black or African American
Native Hawaiian or Other Pacific Islander	White

4. How many years have you lived in your current home?

Note: If parent is assisting in response, please ask how long the child has lived in the home.

_____ (months) _____ (years)

• Don’t know

• Refused to answer

5. Is this your full-time residence?

• Yes

• No

If No, how much time do you reside at this address?

___ Days per week ___ Weeks per month ___ Months per year □ Not Applicable

• Don’t know

• Refused to answer

6. How many 8-oz cups of tap water or beverages prepared with tap water do you drink per day at home?

• _ _ _ (8-oz 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)

7. How frequently do you play in or touch the soil or dirt in [insert affected area/sampling frame/locations]? (Select one)

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Refused to answer

8. If you play in or touch the soil or dirt, at what address or place (e.g. daycare) does this occur (list all locations)? If you play in or touch the soil or dirt at more than one location, what percentage of your total contact with soil happens at each location (percentages should sum to 100%)?

_____________________________________________________________________________

_____________________________________________________________________________

• Don’t know

• Refused to answer

• Not Applicable

9. During the growing season, how often do you eat vegetables or fruits grown at your home or other locally grown vegetables or fruits from (insert affected area/sampling frame/locations)? (Select one)

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

10. How often do you eat fish locally caught from ponds, lakes or rivers in (insert affected area/sampling frame/locations)? (Select one)

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

11. How often do you consume milk from animals raised on farms within (insert sampling/affected area/location or list of affected farms)?

• Every day

• Once per week

• Once per month

• A few times per year

• Rarely

• Never

• Don’t know

• Refused to Answer

12. Did you drink formula reconstituted with tap water as an infant?

• Yes

If Yes, for how long? ____ (months)

• No

• Don’t know

• Refused to answer

• Not Applicable

13. Are you currently, or were you previously breastfed?

• Yes

If Yes, for how long? ____ (months)

• No

• Don’t know

• Refused to answer

• Not Applicable

14. Are you currently attending, or have you attended, a school or daycare?

• Yes

• No

• Don’t know

• Refused to answer

• Not Applicable

15. Please provide the name of your school or daycare and duration you attended each school/daycare, as well as the main drinking water source (public water, private well, community well, bottled water, water from home, don’t know), if known.

Name of School/Daycare	Address	Duration Attended		Located in Affected area?		Main Drinking Water Source
		Start Year	End Year	Yes	No

16. How many 8-oz cups of water or beverages prepared with tap water do you drink per day at day care/school?

______

• 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)

17. Have you ever had your blood tested for PFAS?

• Yes

• No

• Don’t Know

If yes, when, where, and what was the result?

Date of PFAS Test	Who conducted test?	Results

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

____________________________________________________________________________

*** THANK YOU***