Environmental Factors

[ATSDR] National Amyotrophic Lateral Sclerosis (ALS) Registry

P_AppE5 - Environmental Factors

Follow-up Questions - Environmental Factors

OMB: 0923-0041

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Form Approved

OMB No. 0923-0041

Exp. Date 01/31/2023

APPENDIX E5

EVIRONMENTAL FACTORS

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ATSDR estimates the average public reporting burden for this collection of information as 23 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 (0923-0041).


5.1 OCCUPATION

Follow-up questions are based on:

Q: What is your current employment status?

ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS (SEE BELOW)

19

S2_Q01

1

Full-time employed

APPENDIX ITEM 5.1.1 /5.1.2 SERIES

 

 

2

Part-time employed

APPENDIX ITEM 5.1.1 /5.1.2 SERIES

 

 

3

Retired

APPENDIX ITEM 5.1.2 SERIES

 

 

4

Disabled

APPENDIX ITEM 5.1.2 SERIES

 

 

5

Full-time student

APPENDIX ITEM 5.1.2 SERIES

 

 

6

Homemaker

APPENDIX ITEM 5.1.2 SERIES



7

Unemployed

APPENDIX ITEM 5.1.2 SERIES


For those who are currently employed (full or part-time), the following questions are asked for more detailed information about the occupation background.


APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.1.1

S2_Q02_01

 

What is your job title?


 

1

Accountant, auditor, or bookkeeper


 

2

Automotive mechanic, technician, or gas station attendant


 

3

Carpenter or cabinet maker


 

4

Chief executive or owner


 

5

Childcare or home health worker


 

6

Construction worker, laborer, roofer or painter


 

7

Cook, restaurant worker, or food server


 

8

Electrician or electrical worker


 

9

Engineer, architect or draftsperson


 

10

Farmer, gardener or animal worker


 

11

Freight mover, stock clerk or order filler


 

12

Janitor, maintenance worker or house cleaner


 

13

Lawyer or paralegal


 

14

Manufacturing laborer, production worker, or assembler/fabricator


 

15

Physician, nurse, dental or health care worker


 

16

Police officer, sheriff, or security guard


 

17

Retail salesperson, sales clerk, or sales representative


 

18

Secretary, administrative assistant or receptionist


 

19

Steel or sheet metal worker, tool and die worker


 

20

Supervisor or manager of construction or extraction workers


 

21

Supervisor or manager of financial or marketing workers


 

22

Supervisor or manager of manufacturing or production workers


 

23

Supervisor or manager of wholesale or retail sales workers


 

24

Teacher, professor or educator


 

25

Truck driver, taxi driver, chauffeur, delivery person


 

26

Welder, solderer, brazing worker


 

27

Other (specify):

 

S2_Q02_01_01

 

ENTER:

5.1.1.1

S2_Q02_02

 

Industry

 

 

 

ENTER: SEE INDUSTRY

5.1.1.2

S2_Q02_03

 

Industry subcategories

 

 

 

ENTER: SEE INDUSTRY SUBCATEGORIES

5.1.1.3

S2_Q03

 

For how many years were you employed in this occupation?

 

 

 

ENTER:



Same questions (APPENDIX ITEM 5.1.1) are asked for the longest held job, when any employment status is chosen from Essential Questionnaire ITEM 35.


Longest job held

APPENDIX ITEM 5.1.2

S2_Q04_01

S2_Q04_01_01

S2_Q04_02

S2_Q04_03

S2_Q05





APPENDIX E5

EVIRONMENTAL FACTORS


5.2 OCCUPATION-RELATED EXPOSURES


We are interested in those products that you personally handled on the JOB, either by preparing them prior to application, by applying them yourself or by helping to clean up after they were applied.


Follow-up questions are based on:

Q: Over your lifetime (at least 100 days or more), have you ever had a job where you worked with the following pesticides? (Check all that apply)




ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

22

S9_Q01

1

Herbicides

APPENDIX ITEM 5.2.1 SERIES

 

S9_Q02

2

Fungicides

APPENDIX ITEM 5.2.2 SERIES

 

S9_Q03

3

Insecticides

APPENDIX ITEM 5.2.3 SERIES

 

S9_Q04

4

Rodenticides

APPENDIX ITEM 5.2.4 SERIES

 

S9_Q05

5

Fumigants

APPENDIX ITEM 5.2.5 SERIES


APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.2.1

S9_Q01A


At what age did you FIRST handle (ITEM 38)?

 



ENTER:

 

S9_Q01B


At what age did you LAST handle (ITEM 38)?

 



ENTER:

 

S9_Q01C


This is a total of __ __ years. For how many of those years did you NOT use (ITEM 38)?

 

S9_Q01D


ENTER:



Same questions (APPENDIX ITEM 5.2.1) are asked for the chosen pesticides from Essential Questionnaire ITEM 38

Fungicides

Insecticides

Rodenticides

Fumigants

APPENDIX ITEM 5.2.2

APPENDIX ITEM 5.2.3

APPENDIX ITEM 5.2.4

APPENDIX ITEM 5.2.5

S9_Q02A

S9_Q03A

S9_Q04A

S9_Q05A

S9_Q02B

S9_Q03B

S9_Q04B

S9_Q05B

S9_Q02C

S9_Q03C

S9_Q04C

S9_Q05C

S9_Q02D

S9_Q03D

S9_Q04D

S9_Q05D









Follow-up questions are based on:

Q: Over your lifetime (at least 100 days or more), have you ever had a job where you worked with the following chemicals? (Check all that apply)


ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

23

S9_Q06

1

Glues or adhesives

APPENDIX ITEM 5.2.6 SERIES

 

S9_Q07

2

Solvents/degreasers

APPENDIX ITEM 5.2.7 SERIES

 

S9_Q08

3

Unleaded gasoline

APPENDIX ITEM 5.2.8 SERIES

 

S9_Q10

4

Unleaded paint

APPENDIX ITEM 5.2.9 SERIES

 

S9_Q12

5

Formaldehyde

APPENDIX ITEM 5.2.10 SERIES


S9_Q16

6

Other chemicals

APPENDIX ITEM 5.2.11 SERIES



APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.2.6

S9_Q06A

 

At what age did you FIRST handle (ITEM 39)?

 

 

 

ENTER:

 

S9_Q06B

 

At what age did you LAST handle (ITEM 39)?

 

 

 

ENTER:

 

S9_Q06C

 

This is a total of __ __ years. For how many of those years did you NOT use (ITEM 39)?

 

S9_Q06D

 

ENTER:



Same questions (APPENDIX ITEM 5.2.6) are asked for the chosen chemicals from Essential Questionnaire ITEM 39


Solvents/degreasers

Unleaded gasoline

Unleaded paint

Formaldehyde

Other chemicals

APPENDIX ITEM 5.2.7

APPENDIX ITEM 5.2.8

APPENDIX ITEM 5.2.9

APPENDIX ITEM 5.2.10

APPENDIX ITEM 5.2.11

S9_Q07A

S9_Q08A

S9_Q10A

S9_Q12A

S9_Q16A

S9_Q07B

S9_Q08B

S9_Q10B

S9_Q12B

S9_Q16B

S9_Q07C

S9_Q08C

S9_Q10C

S9_Q12C

S9_Q16C

S9_Q07D

S9_Q08D

S9_Q10D

S9_Q12D

S9_Q16D












Follow-up questions are based on:

Q: Over your lifetime (at least 100 days or more), have you ever had a job where you worked with the following metals or metal fumes? (Check all that apply)


ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

24

S9_Q09

1

Leaded gasoline

APPENDIX ITEM 5.2.12

 

S9_Q11

2

Lead paint

APPENDIX ITEM 5.2.13

 

S9_Q13

3

Soldering

APPENDIX ITEM 5.2.14/5.1.12.1

 

S9_Q14

4

Welding/brazing/flame cutting

APPENDIX ITEM 5.2.15/5.1.12.2

 

S9_Q15

5

Metal dust/fume

APPENDIX ITEM 5.2.16/5.1.12.2



APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.2.12

S9_Q09A

At what age did you FIRST handle (ITEM 40)?

 

 

 

ENTER

 

S9_Q09B

At what age did you LAST handle (ITEM 40)?

 

 

 

ENTER

 

S9_Q09C

This is a total of __ __ years. For how many of those years did you NOT use (ITEM 40)?

 

S9_Q09D

ENTER

5.2.12.1

 

 

What specific metals or materials did you work on (ITEM 40; RESPONSE 3)?

 

S9_Q13E_01

 

Tin

 

S9_Q13E_02

 

Silver

 

S9_Q13E_03

 

Other metals or alloy

 

S9_Q13E_04

 

ENTER:

 

 

 

Don't know

5.2.12.2

 

 

What specific metals or materials did you work on (ITEM 40; RESPONSE 4 OR 5)?

 

S9_Q14E_01

 

Steel

 

S9_Q14E_02

 

Iron/copper/aluminum

 

S9_Q14E_03

 

Brass or bronze

 

S9_Q14E_04

 

Lead

 

S9_Q14E_05

 

Other metals or alloy

 

S9_Q14E_06

 

ENTER

 

 

 

Don't know


Same questions (APPENDIX ITEM 5.2.12 and 5.2.12.1 OR 5.2.12.2) were asked for the chosen metal/metal dust or fume from Essential Questionnaire ITEM 40


Lead paint

Soldering

Welding/brazing/flame cutting

Metal dust/fume

APPENDIX ITEM 5.2.13

APPENDIX ITEM 5.2.14/5.2.12.1

APPENDIX ITEM 5.2.15/5.2.12.2

APPENDIX ITEM 5.2.16/5.2.12.2

S9_Q11A

S9_Q13A

S9_Q14A

S9_Q15A

S9_Q11B

S9_Q13B

S9_Q14B

S9_Q15B

S9_Q11C

S9_Q13C

S9_Q14C

S9_Q15C

S9_Q11D

S9_Q13D

S9_Q14D

S9_Q15D


S9_Q13E_01 - 04

S9_Q14E_01 - 06

S9_Q15E_01 - 06

APPENDIX E5

EVIRONMENTAL FACTORS


5.3 PERSONALLY HANDLED OR HOBBIE-RELATED EXPOSURES


Follow-up questions are based on:

Q: Over your lifetime (at least 100 days or more), have you ever personally handled any of the following outside the job (such as home or garden) for a potential exposure to pesticides? (Check all that apply)

ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

25

S10_Q03

1

Herbicides

APPENDIX ITEM 5.3.1/ 5.3.1.1

 

S10_Q04

2

Fungicides

APPENDIX ITEM 5.3.2/ 5.3.1.1

 

S10_Q01

3

Insecticides

APPENDIX ITEM 5.3.3/ 5.3.1.1

 

S10_Q02




 

S11_Q09

4

Gardening

APPENDIX ITEM 5.3.4/ 5.3.1.2



APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.3.1

S10_Q03A


At what age did you FIRST handle (ITEM 41)?

 

 


ENTER:

 

S10_Q03B


At what age did you LAST handle (ITEM 41)?

 

 


ENTER:

 

S10_Q03C


This is a total of __ __ years. For how many of those years did you NOT use (ITEM 41)?

 

S10_Q03D


ENTER:

5.3.1.1



Number of days per year used


S10_Q03E


ENTER:

5.3.1.2

S11_Q09E


Number of hours per month used




ENTER:



Same questions (APPENDIX ITEM 5.3.1 AND either 5.3.1.1 or 5.3.1.2) are asked for the chosen pesticide exposure from Essential Questionnaire ITEM 41

Fungicides

Insecticides

Gardening

APPENDIX ITEM 5.3.2/5.3.1.1

APPENDIX ITEM 5.3.3/5.3.1.1

APPENDIX ITEM 5.3.4/5.3.1.2

S10_Q04A

S10_Q01A

S11_Q09A

S10_Q04B

S10_Q01B

S11_Q09B

S10_Q04C

S10_Q01C

S11_Q09C

S10_Q04D

S10_Q01D

S11_Q09D

S10_Q04E

S10_Q01E

S11_Q09E







Follow-up questions are based on:

Q: Have you ever personally handled any of the following outside job (such as home or garden) for a potential exposure to chemicals? (Check all that apply)


ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

26

S10_Q05

1

Pet tick/flea treatment (soaps, shampoos, dips, or powder)

APPENDIX ITEM 5.3.5/5.3.5.1

 

S11_Q01

2

Leatherwork

APPENDIX ITEM 5.3.6/5.3.5.2

 

S11_Q03

3

Oil-based painting

APPENDIX ITEM 5.3.7/5.3.5.2

 

S11_Q05

4

Woodworking

APPENDIX ITEM 5.3.8/5.3.5.2

 

S11_Q06

5

Car or tire repairing/restoring/oil change

APPENDIX ITEM 5.3.9/5.3.5.2


S11_Q07

6

Using glue to build wooden/plastic models

APPENDIX ITEM 5.3.10/5.3.5.2


S11_Q08

7

Developing photographs

APPENDIX ITEM 5.3.11/5.3.5.2



APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.3.5

S10_Q05A


At what age did you FIRST handle (ITEM 42)?

 

 


ENTER:

 

S10_Q05B


At what age did you LAST handle (ITEM 42)?

 

 


ENTER:

 

S10_Q05C


This is a total of __ __ years. For how many of those years did you NOT use (ITEM 42)?

 

S10_Q05D


ENTER:

5.3.5.1

S10_Q05E


Number of days per year used




ENTER:

5.3.5.2

S11_Q01E


Number of hours per month used




ENTER:



Same questions (APPENDIX ITEM 5.3.5 AND 5.3.5.2) are asked for the chosen chemical exposure from Essential Questionnaire ITEM 42

Leatherwork

Oil-based painting

Woodworking

Car/Tire repairing/restoring/oil change

Using glue for wooden/plastic model

Developing photograph

APPENDIX ITEM 5.3.6

APPENDIX ITEM 5.3.7

APPENDIX ITEM 5.3.8

APPENDIX ITEM 5.3.9

APPENDIX ITEM 5.3.10

APPENDIX ITEM 5.3.11

S11_Q01A

S11_Q03A

S11_Q05A

S11_Q06A

S11_Q07A

S11_Q08A

S11_Q01B

S11_Q03B

S11_Q05B

S11_Q06B

S11_Q07B

S11_Q08B

S11_Q01C

S11_Q03C

S11_Q05C

S11_Q06C

S11_Q07C

S11_Q08C

S11_Q01D

S11_Q03D

S11_Q05D

S11_Q06D

S11_Q07D

S11_Q08D

S11_Q01E

S11_Q03E

S11_Q05E

S11_Q06E

S11_Q07E

S11_Q08E






Follow-up questions are based on:

Q: Have you ever personally handled any of the following outside job (such as home or garden) for a potential exposure to metals? (Check all that apply)


ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

27

S11_Q02

1

Glazing pottery/ceramics


APPENDIX ITEM 5.3.12/5.3.12.1

 

S11_Q04

2

Remodeling/paint scraping on homes built before 1960

APPENDIX ITEM 5.3.13/5.3.12.1

 

S11_Q010

3

Soldering, welding, metal work

APPENDIX ITEM 5.3.14/5.1.12.1

 

S11_Q011

4

Outdoor hunting or shooting

APPENDIX ITEM 5.2.15/5.3.12.2

 

S11_Q012

5

Indoor range gun shooting

APPENDIX ITEM 5.2.16/5.1.12.1


S11_Q013

6

Bullet casting or reloading

APPENDIX ITEM 5.2.17/5.1.12.1


S11_Q014

7

Fishing with lead weights/sinkers

APPENDIX ITEM 5.2.18/5.1.12.1


S11_Q015

8

Knitting and jewelry making/Other hobbies (1)

APPENDIX ITEM 5.2.19/5.1.12.1


S11_Q016

9

Other Hobbies (2)

APPENDIX ITEM 5.2.20/5.1.12.1



APPENDIX ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

5.3.12

S11_Q02A

At what age did you FIRST handle (ITEM 40)?

 

 

 

ENTER

 

S11_Q02B

At what age did you LAST handle (ITEM 40)?

 

 

 

ENTER

 

S11_Q02C

This is a total of __ __ years. For how many of those years did you NOT use (ITEM 40)?

 

S11_Q02D

ENTER

5.3.12.1

S11_Q02E


Number of hours per month used




ENTER:

5.3.12.2

S11_Q011E


Number of hours per YEAR used




ENTER:



Same questions (APPENDIX ITEM 5.3.12 AND either 5.3.12.1 or 5.3.12.2) were asked for the chosen metal exposure from Essential Questionnaire ITEM 43


Remodeling/paint scraping home

Soldering, welding, metal work

Outdoor hunting or shooting

Indoor range gun shooting

APPENDIX ITEM 5.3.13/5.3.12.1

APPENDIX ITEM 5.3.14/5.1.12.1

APPENDIX ITEM 5.2.15/5.3.12.2

APPENDIX ITEM 5.2.16/5.3.12.1

S11_Q04A

S11_Q010A

S11_Q011A

S11_Q012A

S11_Q04B

S11_Q010B

S11_Q011B

S11_Q012B

S11_Q04C

S11_Q010C

S11_Q011C

S11_Q012C

S11_Q04D

S11_Q010D

S11_Q011D

S11_Q012D

S11_Q04A

S11_Q010E

S11_Q011E

S11_Q012E














Bullet casting or reloading

Fishing with lead weights/sinkers

Knitting and jewelry making/ Other hobbies (1)

Other Hobbies (2)

APPENDIX ITEM 5.3.17/5.3.12.1

APPENDIX ITEM 5.3.18/5.1.12.1

APPENDIX ITEM 5.2.19/5.3.12.2

APPENDIX ITEM 5.2.20/5.3.12.1

S11_Q013A

S11_Q014A

S11_Q015A

S11_Q016A

S11_Q013B

S11_Q014B

S11_Q015B

S11_Q016B

S11_Q013C

S11_Q014C

S11_Q015C

S11_Q016C

S11_Q013D

S11_Q014D

S11_Q015D

S11_Q016D

S11_Q013A

S11_Q014E

S11_Q015E

S11_Q016E












APPENDIX E5

EVIRONMENTAL FACTORS


5.4 RESIDENCE HISTORY SURVEY


Follow-up questions are based on:

Q: To the best of your knowledge, have you ever lived for more than 6 months in areas with following environment AT BIRTH? (Check all that apply)

ITEM

VARIABLE CODE

RESPONSE

DESCRIPTION

FOLLOW-UP QUESTIONS

(SEE BELOW)

28a

S8_Q04

1

Farm or ranch

RESIDENCE HISTORY SURVEY


S8_Q05

2

Private well as source of water

RESIDENCE HISTORY SURVEY

 

S8_Q06

3

Within ¼ miles of agricultural area sprayed with pesticides/herbicides

RESIDENCE HISTORY SURVEY



4

Don’t know

RESIDENCE HISTORY SURVEY

28b

S8_Q07

2=No

Current residence?

RESIDENCE HISTORY SURVEY


We are interested in the location of your residences for all the places where you lived for a period of 6 months or longer. Starting with the place where you were born, indicate the city and state (or country) of each place where you lived for 6 months or longer. If you lived on a farm, please give the nearest city or town. If you moved to a different residence within the same city, please include each home or dwelling as a separate entry.

CODE

DESCRIPTION

S8_Q01

At what age did you move to next residence of 6 months or longer


ENTER:

S8_Q02

City or town of residence


ENTER:

S8_Q03A

State of residence


see STATE & PROVINCES

S8_Q03B

Country of residence


see COUNTRY

S8_Q04

Farm or Ranch residence

1

Yes

2

No

9

Don’t know

S8_Q05

Was main source of drinking water from a private well

1

Yes

2

No

9

Don’t know

S8_Q06

Was residence within 1/4 mile of agricultural area that was sprayed with pesticides or herbicides

1

Yes

2

No

9

Don’t know

S8_Q06A

How often did pest or herbicide spraying happen?

1

<1 time/year

2

1-3 times/year

3

4 times/year

9

Don’t know

S8_Q07

Was (is) this your current or most recent residence

1

Yes

2

No

9

Don’t know



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