Environmental Factors

Form Approved

OMB No. 0923-0041

Exp. Date 01/31/2023

APPENDIX E5

EVIRONMENTAL FACTORS

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