Child Questionnaire - Short Form

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

P_Att17a_PeaseChildQstnnr_ShortForm 20190813 clean

OMB: 0923-0061

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Attachment 17a.

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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

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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. |_________________|

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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


  1. Allergies?

Yes (Please specify)__________________

No

Don’t know

  1. Atopic dermatitis/eczema?

Yes (Please specify)__________________

No

Don’t know

  1. Asthma?

Yes

No

Don’t know

  1. Stuffy/runny nose?

Yes

No

Don’t know

  1. High cholesterol?

Yes

No

Don’t know

  1. Thyroid disease?

Yes (Please specify)__________________

No

Don’t know

  1. Delayed puberty?

Yes (Please specify) _________________

No

Don’t know

  1. Obesity?

Yes

No

Don’t know

  1. Lupus

Yes

No

Don’t know

  1. Celiac disease

Yes

No

Don’t know

  1. Type 1 diabetes

Yes

No

Don’t know

  1. Scleroderma

Yes

No

Don’t know

  1. Cancer?

Yes (Please specify) ________________

No

Don’t know

  1. Attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD)?

Yes

No → go to o

Don’t know → go to o

  1. Autism?

Yes

No → go to p

Don’t know → go to p

  1. 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?

  1. Thyroid disease?

Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Lupus?

Yes

No

Don’t know

Child

Parent

Sibling

  1. 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

  1. Celiac disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Crohn’s disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Asthma?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Scleroderma

Yes

No

Don’t know

Child

Parent

Sibling

  1. High Cholesterol

Yes

No

Don’t know

Child

Parent

Sibling

  1. Allergies

Yes (Please specify)__________________

No

Don’t know

Child

Parent

Sibling

  1. Atopic dermatitis/eczema

Yes

No

Don’t know

Child

Parent

Sibling

  1. Attention deficit hyperactivity disorder (ADHD or attention deficit disorder (ADD)

Yes

No

Don’t know

Child

Parent

Sibling

  1. Autism

Yes

No

Don’t know

Child

Parent

Sibling

  1. Other learning or behavioral problems

Yes

No

Don’t know

Child

Parent

Sibling

  1. 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.



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AuthorBove, Frank J. (ATSDR/DTHHS/EEB)
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