Form 0923-0048 Participant Questionnaire

Appendix E1: JNC EI Questionnaire

Form Approved

OMB No. 0923-0048

Exp. Date 06/30/2022

Participant ID

Jasper and Newton Counties Exposure Investigation Questionnaire

Oronogo-Duenweg Mining Belt and

Newton County Mine Tailings Sites

ATSDR estimates the average public reporting burden for this collection of information as 20 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).

Flesch Kincaid Reading Level: Grade 5.1

Introduction – Hello my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. As part of this investigation, we will be asking you some common questions to better understand the data we collect.

The questions should take about 20 minutes. After that, we will be offering free blood lead testing. Follow up environmental sampling of yards, water, and households for participants in this exposure investigation will be completed at a later date. Once we are done with the investigation, you will be sent the results of your testing. We anticipate providing you the blood lead results within 12 weeks.

Cost Recovery Numbers: 70RZ, 70HK, 7036

1. Person administering questionnaire _____________________________________________

2. Date questionnaire administered _______________________________________________

3. Participant last name ________________________________________________________

4. Participant first name ________________________________________________________

5. Address ___________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

6. County ____________________________________________________________________

7. Laboratory ID______________________________________________________________

Household Questionnaire:

8. How long have you (or your child) lived at your current address?

☐ Less than 6 months

☐ 6 months to less than 2 years

☐ 2 to 5 years

☐ 6 to 10 years

☐ More than 10 years

9. Do you live in a(n)

☐ Apartment

☐ Single family home

☐ Mobile home

☐ Other

10. Do you rent or own?

☐ Rent

☐ Own

11. About when was the home built?

☐ 2000 to present

☐ 1990 to 1999

☐ 1980 to 1989

☐ 1970 to 1979

☐ 1960 to 1969

☐ 1950 or earlier

☐ Don’t know

12. How would you rate the condition of your home or building?

☐ Good

☐ Fair

☐ Poor

13. What type of exterior does the home have?

☐ Wood

☐ Brick

☐ Block

☐ Vinyl/metal

☐ Stucco

☐ Other

14. Do the windows (e.g., windowsills, frames) inside the home have peeling paint?

☐ YES

☐ NO

15. Is there peeling paint in other places inside, such as cabinets or interior walls?

☐ YES

☐ NO

16. Is there peeling paint in other places outside, such as exterior walls and porches?

☐ YES

☐ NO

17. Have any parts of your home been repainted, sanded, or otherwise refinished within the last year?

☐ YES

☐ NO

☐ Don’t know

If YES, approximately when and how? __________________________________________

18. What type of water does the household normally use?

☐ Private well water

☐ Public water (city or districts)

☐ Other (specify) _____________________________

19. Do you have a water filtration system?

☐ YES

☐ NO

If YES, what type of system and where is it located? ________________________________

___________________________________________________________________________

20. Has anyone ever used any material from mines or smelters, such as chat or slag, in or around your house or yard?

☐ YES

☐ NO

☐ Don’t know

21. Does your home have a yard with bare dirt?

☐ YES

☐ NO

22. Has your yard ever been tested for lead?

☐ YES

☐ NO

☐ Don’t know

23. If YES, can you provide additional information?

Who tested your yard? ________________________________________________________

When was your yard tested? ___________________________________________________

Which area was tested? _______________________________________________________

What were the levels? ________________________________________________________

Was your yard cleaned up and if so when? ________________________________________

24. Has your tap water ever been tested for lead?

☐ YES

☐ NO

☐ Don’t know

25. If YES, can you provide additional information?

Who tested your water? _______________________________________________________

When was your water tested? __________________________________________________

What was the level? _________________________________________________________

26. How often do members of the household remove shoes before entering the home?

☐ Always

☐ Sometimes

☐ Rarely

☐ Never

27. Does your family wash their hands before eating?

☐ Always

☐ Sometimes

☐ Rarely

☐ Never

28. Do you have any pets that go in and out of the house?

☐ YES

☐ NO

29. Does your household grow food in a garden?

☐ YES

☐ NO

30. How often do you vacuum your home?

☐ Daily

☐ Several times a week

☐ Weekly

☐ Monthly

☐ Other

31. How often do you mop your home?

☐ Daily

☐ Several times a week

☐ Weekly

☐ Monthly

☐ Other

32. How often do you dry sweep your home?

☐ Daily

☐ Several times a week

☐ Weekly

☐ Monthly

☐ Other

33. How often do you dust your home?

☐ Daily

☐ Several times a week

☐ Weekly

☐ Monthly

☐ Other

Minor Participants:

34. Name of person answering questions for minor child________________________________

35. Relationship to child/ward:

☐ Mother

☐ Father

☐ Guardian

36. What is your child’s/ward’s date of birth?

Date of Birth ______________________

37. Do you consider your child/ward to be Hispanic, Latino, or of Spanish origin?

☐ YES

☐ NO

38. Which one or more of the following would you say is your child’s/ward’s race?

☐ White

☐ American Indian or Alaska Native White

☐ Black or African American

☐ Hispanic or Latino

☐ Native Hawaiian or Other Pacific Islander

☐ Asian

☐ Participant declined to answer

39. Has your child/ward ever had their blood tested for lead?

☐ YES

☐ NO

40. ☐ Don’t knowIf YES, when, where, and what was the result? _____________________________________

___________________________________________________________________________

41. Does your child/ward go to daycare, school, or another location during the day that isn’t your child’s home?

☐ YES

☐ NO

42. If YES, how many hours per day does your child/ward spend at daycare, school, or another location that is not your child’s home?

☐ 1 to 4 hours

☐ 5 to 8 hours

☐ Over 8 hours

☐ Don’t know

43. How many times per week does your child/ward go to daycare, school, or another location that is not your child’s home?

☐ 1 to 3 days per week

☐ 4 or more days per week

☐ Don’t know

44. Does your child/ward suck his/her thumb, put their hands in their mouth, and/or chew nonfood items such as toys and windowsills?

☐ YES

☐ NO

45. If YES, how often?

☐ Frequently

☐ Sometimes

☐ Rarely

46. How many hours per day does your child/ward typically play in your yard?

☐ 1 to 2 hours

☐ 3 to 4 hours

☐ 5 to 6 hours

☐ Over 7 hours

47. Where does your child/ward typically play in your yard?

☐ Playground

☐ Garden

☐ Other (specify) ___________________________________________________________

48. Have you noticed your child/ward eating dirt while playing outside?

☐ YES

☐ NO

49. If yes, how often?

☐ Frequently

☐ Sometimes

☐ Rarely

50. Does your child/ward drink water from the kitchen tap? This includes tap water used to make formula juice or soup.

☐ YES

☐ NO

51. If YES, how much does your child/ward drink daily (including formula, juice, or soup made with tap water)?

☐ 1 to 2 cups

☐ 3 to 4 cups

☐ More than 5 cups

52. Has your child/ward used any home (folk) remedies in the past month for any illnesses?

☐ YES

☐ NO

☐ Don’t know

53. Has your child/ward eaten any imported candy in the past month?

☐ YES

☐ NO

☐ Don’t know

54. Has the COVID-19 pandemic led to you or your child/ward spending more time in your home?

☐ YES

☐ NO

55. Is there anything you want us to know about you or your child that we did not ask about? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Adult Participants:

56. What is your date of birth?

Date of Birth ______________________

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

☐ YES

☐ NO

58. Which one or more of the following would you say is your race?

☐ White

☐ American Indian or Alaska Native

☐ Black or African American

☐ Hispanic or Latino

☐ Native Hawaiian or Other Pacific Islander

☐ Asian

☐ Participant declined to answer

59. If female between 15-44 years old, are you pregnant? If YES, in what month of pregnancy?

☐ Don’t know

☐ NO

☐ YES, 0 to 3 months

☐ YES, 4 to 6 months

☐ YES, 7 to 9 months

60. What is the highest level of education you have completed?

☐ No schooling

☐ Elementary school (Grades 1-8)

☐ High school or GED (Grades 9-12)

☐ Technical or trade school

☐ Junior/Community college

☐ Four-year college/university

☐ Attended graduate school (or higher)

☐ Participant declined to answer

61. Including you, how many people live in your household? ____________________________

62. How many are younger than 6 years old? _____________________________________________

63. Have you ever had your blood tested for lead?

☐ YES

☐ NO

☐ Don’t know

64. If YES, when, where, and what was the result? _____________________________________

___________________________________________________________________________

65. Do you work, go to school, or spend time in another location that is not your home?

☐ YES

☐ NO

66. If YES, how much time per day do you work, go to school, or spend time in another location that is not your home?

☐ 1 to 2 hours

☐ 3 to 4 hours

☐ 5 to 6 hours

☐ Over 7 hours

67. How many times per week do you work, go to school, or spend time in another location that is not your home?

☐ 1 to 3 days per week

☐ 4 or more days per week

☐ Don’t know

68. How many hours per day do you typically spend outdoors or working in your yard?

☐ Less than 1 hour

☐ 1 to 2 hours

☐ 3 to 6 hours

☐ Over 7 hours

69. Do you drink water from the kitchen tap? This includes tap water used to make formula, coffee, tea, juice, or soup.

☐ YES

☐ NO

70. If YES, how much do you drink daily (including coffee, tea, juice, or soup made with tap water)?

☐ 1 to 2 cups

☐ 3 to 4 cups

☐ More than 5 cups

71. Have you used any imported pottery, glassware, or cookware in the past month?

☐ YES

☐ NO

☐ Don’t know

☐ If YES, specify: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________

72. Have you used any home (folk) remedies in the past month for any illnesses?

☐ YES

☐ NO

☐ Don’t know

☐ If YES, specify: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________

73. Have you eaten any imported candy in the past month?

☐ YES

☐ NO

☐ Don’t know

☐ If YES, specify: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________

74. Do you own any imported toys or costume jewelry that are over 10 years old?

☐ YES

☐ NO

☐ Don’t know

☐ If YES, specify: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________

75. Do you have any hobbies that may involve exposure to lead?

☐ YES

☐ No

☐ Don’t know

76. If YES, what type of hobby?

☐ Stained glass

☐ Firing range

☐ Leaded fishing lures

☐ Metal working

☐ Other (specify) _________________________________________________________

77. Do any members of your household work in a job where lead might be present or used (e.g., landscaping, construction worker, mine or mine-related job, battery worker, ammunition manufacturer, oil field worker, radiator repair)?

☐ YES

☐ NO

☐ Don’t Know

If YES, please specify: _______________________________________________________

78. If YES, does that household member wear his/her work clothes and shoes home after working?

☐ YES

☐ NO

79. Has the COVID-19 pandemic led to you spending more time in your home?

☐ YES

☐ NO

80. Is there anything you want us to know about you that we did not ask about? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________