0923-0048 Personal Exposure Questionnaire - Child (12-17 Years)

Appendix C3: Personal Exposure Questionnaire (Child)

Form Approved

OMB No. 0923-0048

Exp. Date 4/30/2022

Respondent ID No:

Environmental Sampling of PFAS at Selected Exposure Assessment Locations,

Personal Exposure Child (<18 years or age of majority) Questionnaire

ATSDR estimates the average public reporting burden for this collection of information as 15 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).

Thank you for participating in the environmental sampling Exposure Investigation (EI).

This personal exposure questionnaire should be completed by children (with parental assistance as needed) in the household that:

• Provided a blood sample during the Exposure Assessment

• Have a completed Parental Permission form

• Have a completed Assent form, if the child is between 12 and 17 years old

ATSDR will pick up this form from you when we come to your home for the environmental sampling.

Demographics

Child’s Name: ___________________________________________________

Child’s Date of Birth: _________ (Month/Day/Year)

Address: _________________________________________________

Note: If you are a parent giving the response for your child, please replace “you” in the question with “your child.” Example: How many years has your child lived in his/her current home?

Residence

1. Do you still live in the home you lived in when you were tested during the Exposure Assessment (date of EA)?

• Yes

• No

2. Is this your full-time residence?

• Yes

• No

If No, how much time do you reside at this address?

___ Days per week ___ Weeks per month ___ Months per year

□ Not Applicable

• Don’t know

• Prefer not to answer

If this is not your full-time residence, what is your alternate address?

Address: _________________________________________________

Water

3. Prior to PFAS being mitigated from your water (date of mitigation), on average,how many 8-oz cups of tap water or beverages prepared with tap water did you drink per day at home?

• ____ (8-oz cups)

• Don’t drink tap water

• Don’t know

Note: 1 cup = 8-oz; 2 cups = 1 pint (16-oz); 4 cups = 1 quart (32-oz); 16 cups = 1 Gallon (128-oz)

4. After the PFAS were mitigated from your water (date of mitigation), how many 8-oz cups of tap water or beverages prepared with tap water do you drink at home per day?

• ____ (8-oz cups)

• Don’t drink tap water

• Don’t know

Note: 1 cup = 8-oz; 2 cups = 1 pint (16-oz); 4 cups = 1 quart (32-oz); 16 cups = 1 Gallon (128-oz)

5. How many 8-oz cups of water or beverages prepared with tap water do you drink per day at day care/school?

______

• Don’t go to daycare/school

• Don’t drink tap water

• Don’t know

Note: 1 cup = 8-oz; 2 cups = 1 pint (16-oz); 4 cups = 1 quart (32-oz); 16 cups = 1 Gallon (128-oz)

Outside Exposure

6. How often do you drink water from the hose outside at your home? (Select one)

Rarely	Never	Don’t know
Prefer not to answer

7. How often do you play in or touch the soil or dirt at your own home? (Select one)

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Prefer not to answer

8. How often do you play in or touch the soil or dirt at daycare or school?

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Prefer not to answer

9. Before the pandemic was here (prior to January 2020), how many hours did you spend outdoors on a typical

work/school/daycare day? __________ hours

non work/school/daycare day? __________ hours

10. Since the start of the pandemic (approximately January 2020), how many hours do you spend outdoors on a typical

work/school/daycare day? __________ hours

non work/school/daycare day? __________ hours

11. How often do you remove your shoes when you enter the home?

• Always

• Sometimes

• Never

12. How often do you put soil or dirt in your mouth or get dirt in your mouth from being outside playing or doing sports (if the parent is responding, How often have you observed your child put soil or dirt in his/her mouth?

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Prefer not to answer

13. How often do you eat with your hands or put your hands in your mouth in your mouth?

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Prefer not to answer

14. How often do you eat, chew on, or put non-food items in your mouth (example: toys, windowsill, etc.)

Every day	A few times per week	A few times per month
Rarely	Never	Don’t know
Prefer not to answer

Diet

15. Do you eat locally grown vegetables or fruits?

• Yes 

• No  

• Don’t Know  

 

If yes, how often do you eat locally grown fruits or vegetables? (select one) 

• Every day  

• Once per week  

• Once per month  

• A few times per year  

• Rarely  

• Never  

• Don’t know  

 

If yes, where do you buy these locally grown fruits or vegetables? 

• Farmer’s market  

• Local grocery store 

• Vegetable / fruit stand 

If yes, what time of year do you buy local produce? Please check all that apply.

• Fall

• Winter

• Spring

• Summer

16. Do you eat vegetables or fruits grown at your home?

• Yes 

• No  

• Don’t Know  

If yes, how often do you eat fruits or vegetables grown at your home? (select one) 

• Every day  

• Once per week  

• Once per month  

• A few times per year  

• Rarely  

• Never  

• Don’t know  

If yes, what time of year do you grow vegetables or fruits at your home? Please check all that apply.

• Fall

• Winter

• Spring

• Summer

17. How often do you eat fish locally caught from ponds, lakes, streams, or rivers? (Select one)

• 3 times per week or more  

• A few times per month  

• A few times per year  

• Rarely  

• Never  

• Don’t know  

18. Do you eat fast food or convenience type of foods?

• Yes 

• No  

• Don’t Know  

If yes, how often do you consume fast food? 

• Every day  

• Once per week  

• Once per month  

• A few times per year  

• Rarely  

  • Never  

  • Don’t know  

If yes, what type of fast-food or convenience food products do you generally consume and how often do you consume it?

	How often the fast food or convenience type of food is eaten
	Daily	Once/week	Once/month	Few times/year	Never	Don’t know	Prefer not to answer
Food name
French fries
Take-out pizza (in a box with a separate liner)
Frozen pizza (in a box with a separate liner)
Burgers or sandwiches wrapped in paper
Burgers or sandwiches in cardboard box (fast food paper clamshells)
Frozen convenience meals (in cardboard)
Microwave popcorn

 

 

19. Is there anything else you want to tell us about your PFAS exposures?

____________________________________________________________________________

*** THANK YOU***