PFC Exposure Investigation / Blood and Urine Sampling Qu

Attachment 4

Participant Questionnaire

Decatur, AL

Place ID # label here

U.S. Department of Health and Human Services

Agency for Toxic Substances and Disease Registry

PFC Exposure Investigation, blood and urine sampling Questionnaire

(ATSDR OMB Control No. 0923-0048 / Expiration Date: 5/31/2016)

Name: ___________________________________________________

Date of Birth: _________ (Month/Day/Year) Sex: Male Female

Address: _________________________________________________

1. Are you Hispanic, Latino/a, or Spanish origin? You may skip this question.

• No, not Hispanic, Latino/a

• 

  To be filled out by

  ATSDR Staff:

  
  

  Height: ­­_____________

  
  

  Weight: ____________

  
  

  Body Fat %: _________

  
  

  Urine Volume: _______

  
  

  Yes, Hispanic, Latino/a

2. What is your race? One or more categories may be selected.

You may skip this question.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

3. How many years have you lived at your current address? ­­

­__________ (years)

Don’t Know

Refused to Answer

4. How many years have you lived in the Morgan/Lawrence/Limestone County area? ________ (years)

Don’t Know

Refused to Answer

5. Has your doctor ever told you have:

   Diabetes	Yes	No	Don’t Know	Refused to Answer
   Kidney Disease	Yes	No	Don’t Know	Refused to Answer
   Hepatitis C	Yes	No	Don’t Know	Refused to Answer Know
   Anemia	Yes	No	Don’t Know	Refused to Answer Know

6. Are you currently undergoing dialysis treatment?

Yes No Don’t Know Refused to Answer

If participant is under the age of 17, skip to question #10.

7. To your knowledge, are you pregnant? If participant is male, skip to question #9.

Yes No Don’t Know Not Applicable Refused to Answer

8. Have you completed menopause? If participant is male, skip to question #9.

Yes No Don’t Know Not Applicable Refused to Answer

If yes, how long ago did you complete menopause? __________ (years)

Don’t Know Refused to Answer

9. How frequently do you donate blood and/or plasma (circle one)?

Once per month

A few times per year

Once per year

Rarely

Never

Don’t Know

Refused to Answer

10. Did you participate in the 2010 Exposure Investigation? If no, skip to question 13.

Yes No Don’t Know Refused to Answer

11. If yes, has your address changed?

Yes No Don’t Know Refused to Answer

12. If yes, please select any behaviors that have changed following the 2010 Exposure Investigation:

• My drinking water source changed from private well to public water system.

• My drinking water source changed from private well to bottled water.

• My drinking water source changed from public water system to bottled water.

• I have installed a filtration system on my private well.

• My drinking water source changed in some other way (please explain):
  
  

________________________________________________________________

• My consumption of locally caught fish has increased.

• My consumption of locally caught dish has decreased.

• My consumption of locally grown vegetables has increased.

• My consumption of locally grown vegetables has decreased.

• Other behaviors related to PFC exposure (please explain):

_____________________________________________________________

• Refused to Answer

13. How frequently do you work or play in the soil (e.g. gardening, digging, farming, building, repairing, etc…) (circle one)?

Once per month

A few times per year

Once per year

Rarely

Never

Don’t Know

Refused to Answer

If you work in the soil, at what address or place (e.g. daycare) does this occur (list all locations):

__________________________________________________________________

Refused to Answer

14. How often do you eat “homegrown” or locally grown vegetables (circle one)?

Once per month

A few times per year

Once per year

Rarely

Never

Don’t Know

Refused to Answer

15. How often do you eat fish caught from local ponds, lakes or rivers (circle one)?

Once per month

A few times per year

Once per year

Rarely

Never

Don’t Know

Refused to Answer

16. What is the main source of drinking water in your home (circle one)?

Public – City or County
	Name of water supplier:
Private Well
Spring
Pond
Cistern
Community Well
Bottled Water
Don’t Know Refused to Answer

17. If you have a private well, has it been tested for PFCs?

Yes No Don’t Know Refused to Answer

If yes, do you know the date it was tested, who did the testing, and the results of the PFC testing?

Date (month/year)	Company/Government	PFC Results

18. Please list your job title and where you have worked for the past 20 years. If participant is under the age of 17, skip to end.

Not Applicable

Refused to Answer

Company Name	Job Title	Year Started	Year Ended

*** THANK YOU ***