Agriculture Questionnaire Content_English

Agriculture (Farm, ranch, orchard, or greenhouse)

INFORMED CONSENT FOR BD-STEPS OCCUPATIONAL QUESTIONNAIRE
The Birth Defects Study to Evaluate Pregnancy exposureS (BD-STEPS) is a study to discover clues about what causes
birth defects. You previously completed a telephone interview about experiences during your pregnancy. This
questionnaire asks you additional questions about your experiences during the same pregnancy.
The questionnaire will take about 20 minutes. It includes questions about working on a farm, ranch, orchard, or
greenhouse. Some women may find it emotionally difficult to discuss their pregnancies. There is no other likely risk.
Completing this questionnaire will not benefit you or your family directly; however, the findings may help to
prevent birth defects in the future.
You can choose not to participate. The decision not to participate will not affect the care or services you or your
family receives.
You are free to stop the questionnaire at any time.
We plan to share your questionnaire information with other researchers involved in this study. Information will
only be used for research and it will be kept confidential. It will only be shared after appropriate approvals are
obtained by the study’s Data Sharing Committee and human research protection committees. We will never use
any names or addresses in reports or publications.
If you have any concerns about the study or how it is conducted, you may contact . If you have questions about your rights as a subject in this research study, please call <> OR <>.
Leave a message including your name and telephone number, and refer to Protocol #2087, and someone will call
you back as soon as possible. [NOTE: CDC IRB can be removed if required by Center IRB]
If you wish to participate in this part of our study, please sign this form, complete the questionnaire, and return
both to us in the stamped return envelope. We have included a second copy of this form for you to keep for your
records.

Signature:__________________________________________________ Date:_____________

ID ______________________

Agriculture (Farm, ranch, orchard, or greenhouse)
1. Did you start or stop working in the month before you became pregnant or the first three months of
your pregnancy?
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No  Go to question #4
Yes, I started a new job
Yes, I stopped working at this job
Don’t know  Go to question #4
2. Please enter the date you started this job. If you can’t remember the exact date, please enter
your best estimate. (mm/dd/yyyy):
 Don’t Know  Go to question #4
3. Please enter the date you stopped working in this job. If you can’t remember the exact date,
please enter your best estimates (mm/dd/yyyy):
 Don’t Know
For the remaining questions about your job, please describe what your job was like before you
stopped working.

4. During the month before you became pregnant through the third month of your pregnancy, did
you ask if your work duties could be changed or reduced?
 Yes
 No
 Don’t Know  Go to question #7
5. Were your requests granted?
 Yes, all my requests were granted. For the remaining questions about your job, please
describe what your job was like before your requests were granted.
 Some, but not all, of my requests were granted. For the remaining questions about your
job, please describe what your job was like before some of your requests were granted.
 No, none of my requests were granted.
 Don’t know
Go to question #7
6. Was it because (please check all that apply):
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You did not need your duties to be changed or reduced
You had the flexibility to adjust your work on your own
Your supervisor offered to change or reduce your duties, without you asking
You were uncomfortable or afraid to request it
You did not ask because you knew your request would be denied

ID ______________________

Agriculture (Farm, ranch, orchard, or greenhouse)

7. During the month before you became pregnant through the third month of your
pregnancy, how many shifts per week and how many hours per shift did you typically
work at this job?
Shift (days) per week:

Don’t know

Hours per shift (day):

Don’t know

Of the hours you worked in each shift, how many did you typically spend:
Hours sitting per shift:

Don’t know

Hours standing in one place per shift:

Don’t know

Hours on your feet, but walking or moving around per shift:

Don’t know

8. During the month before you became pregnant through the third month of your
pregnancy, did you work in a:
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
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Family farm, ranch, or orchard owned by yourself or your family?
Family farm, ranch, or orchard owned by someone outside your family?
Large-scale or commercial farm, ranch, or orchard
Greenhouse
Somewhere else, please specify:

9. What were the main products of the farm, ranch, orchard, or greenhouse where you
worked? (please check all that apply):
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Decorative plants such as shrubs, trees, or flower
Clover, hay, or alfalfa
Corn
Soybeans
Wheat
Oats
Poultry
Beef cattle
Dairy cattle
Pigs
Fruits or vegetables:
Other products:

ID ______________________

Agriculture (Farm, ranch, orchard, or greenhouse)

10. Were the products of the farm or greenhouse?
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



Organic
Conventionally-produced
Produced through a mix of organic and conventional practices
Don’t know

11. How often did you mix, transfer, load, or spray pesticides (including weed killers,
fungicides, and insecticides) for your job during the month before you became pregnant
through the third month of your pregnancy?
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
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Never
Less than once a month
Once or twice a month
About once a week
Several times a week
Don’t know

Each selection returns to question 12
12. At work, on average, how many times per day did you lift or carry objects that weigh
15 pounds or more? For reference, 15 pounds is about the weight of 2 gallons of milk.


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< 1 time per day
1-5 times per day
6-10 times per day
11-20 times per day
> 20 times per day
Don’t know

13. At work, on average, how many times per day did your job involve bending at the
waist? This includes bending forward or stooping, bending to the side, and twisting.
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< 1 time per day
1-25 times per day
26-50 times per day
51-75 times per day
> 75 times per day
Don’t know

ID ______________________

Agriculture (Farm, ranch, orchard, or greenhouse)

14. During the month before you became pregnant through the third month of your pregnancy,
how many times per day were you permitted to take bathroom breaks at work?
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None
1
2-3
4-5
As many as I needed/very flexible
Don’t know

15. For the following list of words, please respond with ‘yes’ if the word describes your job, ‘no’ if it
doesn’t or ‘can’t decide’ if you aren’t sure.
Yes
No
Can’t decide
Demanding
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Pressured
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Hectic
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Calm
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Relaxed
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Many things stressful
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Pushed
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Irritating
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Under Control
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Nerve-wracking
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Hassled
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Comfortable
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More stressful than I’d like
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Smooth Running
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Overwhelming
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

ID ______________________

Agriculture (Farm, ranch, orchard, or greenhouse)

16. During the month before you became pregnant through the third month of your pregnancy, did
you find it difficult to take time off work for prenatal visits?
 Yes
 No  Go to Comments
 Don’t know  Go to Comments
17. What were the reasons? (Please check all that apply):
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I felt I was too busy at work to take time off
I felt it would be difficult to get approval from my boss to take the time
The cost – I wouldn’t have gotten paid for the time I was away
I did not have enough sick or vacation leave
I was saving my sick and vacation leave for after the baby was born
Other, please specify:

Please add any comments, concerns and/or suggestions about this survey you may wish to share with us.

Thank you for your time. It is truly appreciated.

ID ______________________