Multi-site Study Adult Questionnaire

Attachment 16.

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

ATSDR estimates the average public reporting burden for this collection of information as 30 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-xxxx).

Multi-site Study Adult Questionnaire

Parent Study ID No. |_________________| (alias, if applicable)

Adult Study ID No. |_________________|

Section A: Demographic Information

A1. What is your age in years?

___ years

___Refused to answer

A2. What is your sex:

___Male

___Female

___Refused to answer

A3. Do you consider yourself to be Hispanic or Latino?

___Yes

___No

___Refused to answer

A4. What race do you consider yourself to be? Mark all that apply.

___American Indian or Alaska Native

___Asian

___Black or African American

___Native Hawaiian or Other Pacific Islander

___White

___Refused to answer

A5. What is the highest level of education you completed?

___Less than high school

___Some high school

___High school graduate or equivalent (GED)

___Some university/college

___Technical or trade school

___University/college graduate

___Graduate school or higher

A6. What is your household income (from all sources)?

___Less than $25,000

___$25,000 to $69,000

___$70,000 to $149,000

___More than $150,000

___Don’t know

___Refused to answer

A7. During the last 12 months did you have any kind of health insurance?

___Yes

___No

___Don’t know

___Refused

Section B: Residential History and Drinking Water Exposures

B1. What is the main source of tap water in your home?

____Public water system

____Private well

____Other: specify ____________________________________

____Don’t know

____Refused to answer

B2. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at home?

___ cups

___Don’t drink tap water

___Don’t know

___Refused to answer

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

B3. What was your previous address?

Street Apt

City State __ __ Zip Code:

B4. When did you move into your previous address? Month____ Year_______

B5. What was the main source of tap water at that address?

____Public water system

____Private well

____Other: specify ____________________________________

____Don’t know

____Refused to answer

B6. On average, how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day when you lived at that address?

___ cups

___Don’t drink tap water

___Don’t know

___Refused to answer

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

B7. Have you lived at any other address since January 2000?

___ Yes

___No → go to Section C

___Don’t know → go to Section C

___Refused to answer → go to Section C

B8. Please fill out the table below for these other residences where you lived since January 2000.

Street Address, City, State	Move in (mm/yy)	Average consumption of tap water per day (# cups)	Main source of tap water at this address (public water system or private well?)

Section C: History of Potential Exposure Modifiers

C1. Have you ever had a blood transfusion?

___Yes → Please specify how many times you had a blood transfusion__________

___No →go to Question C3

___Don’t know →go to Question C3

___Refused to answer →go to Question C3

C2. When did you last have a blood transfusion?

________month/year

C3. Have you ever donated blood?

___Yes→ Please specify how many times you have donated blood__________

___No →go to Question D1

___Don’t know →go to Question D1

___Refused to answer →go to Question D1

C4. When did you last donate blood?

________ Month/Year

C5. On average, how often do you donate blood in a year?

__________

Section D: Occupational History

D1. What is your primary occupation?

_______________________________________

D2. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at work?

___ cups

___Don’t drink tap water

___Don’t know

___Refused to answer

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

D3. Please fill out the table below for each job that lasted one month or more starting from the present and working back to 2000.

Job information	Job 1	Job 2	Job 3	Job 4
a. Where did you work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did you work as a firefighter? If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D DDon’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did you work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

Job information	Job 5	Job 6	Job 7	Job 8
a. Where did you work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did you work as a firefighter? If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D DDon’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did you work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

Job information	Job 9	Job 10	Job 11	Job 12
a. Where did you work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did you work as a firefighter? If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D DDon’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did you work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

Section E: Medical History

E1. Have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? If yes, we may request access to your medical records. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical condition		If yes, what year were you diagnosed?
Thyroid disease?	Yes (Please specify) ______________________ No Don’t know	_ _ _ _ year
High cholesterol?	Yes No Don’t know	_ _ _ _ year
High blood pressure? (not including pregnancy induced hypertension)	Yes No Don’t know	_ _ _ _ year
Heart Disease?	Yes No Don’t know	_ _ _ _ year
Osteoarthritiss?	Yes No Don’t know	_ _ _ _ year
Osteoporosis	Yes No Don’t know	_ _ _ _ year
Endometriosis?	Yes No Don’t know	_ _ _ _ year
Liver disease?	Yes (Please specify) ______________________ No Don’t know	_ _ _ _ year
Kidney disease?	Yes (Please specify) _____________________ No Don’t know	_ _ _ _ year
Ulcerative colitis?	Yes No Don’t know	_ _ _ _ year
Rheumatoid arthritis?	Yes No Don’t know	_ _ _ _ year
Lupus?	Yes No Don’t know	_ _ _ _ year
Multiple sclerosis?	Yes No Don’t know	_ _ _ _ year
Diabetes (not related to pregnancy)?	Yes (Please specify) _____________________ No Don’t know	_ _ _ _ year
Asthma	Yes No Don’t know	_ _ _ _ year
Parkinson Disease	Yes No Don’t know	_ _ _ _ year
Chronic bronchitis	Yes No Don’t know	_ _ _ _ year
Emphysema	Yes No Don’t know	_ _ _ _ year
Fibromyalgia	Yes No Don’t know	_ _ _ _ year
Celiac Disease	Yes No Don’t know	_ _ _ _ year
Crohn’s Disease	Yes No Don’t know	_ _ _ _ year
Scleroderma?	Yes No Don’t know	_ _ _ _ year
Atopic dermatitis/eczema?	Yes (Please specify) _____________________ No Don’t know	_ _ _ _ year
Allergies?	Yes (Please specify) _____________________ No Don’t know	_ _ _ _ year
Infertility?	Yes No Don’t know	_ _ _ _ year

E2. Have you ever been told by a doctor or other health care provider that you have or had a cancer?

____Yes, please specify the cancer_______________

____No → go to Question F1 if male; go to Question E7 if female

____Don’t know → go to Question F1 if male; go to Question E7 if female

E3. In what state were you diagnosed with the cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed

E4. Have you been diagnosed with another cancer?

____Yes, please specify the cancer_______________

____No → go to Question F1 if male; go to Question E7 if female

E5. In what state were you diagnosed with the other cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed

E6. Please list any additional cancer that you were diagnosed with, the year that you were diagnosed, and the state where you were diagnosed:

__________Type of cancer ____________Type of cancer

__________Year diagnosed ___________Year diagnosed

__________State where you were diagnosed __________State where you were diagnosed

FOR WOMEN ONLY

E7. Have you ever used an oral contraceptive (“birth control pill”)?

___Yes

___No → go to Question E9

___Don’t know → go to Question E9

___Refused to answer → go to Question E9

E8. When did you last use an oral contraceptive (“birth control pill”)?

________ Month/Year

E9. At what age did you begin menstruation (have your first period)?

___Age when you began menstruation

___Never menstruated → go to Section F

___Don’t know

E10. Does your period occur regularly (every month)?

___Yes → go to Question E13

___No, it is irregular → go to Question E13

___No, I don’t have a period

___Don’t know → go to Question E13

E11. Why did your periods stop?

___Pregnant

___Menopausal

___Had hysterectomy

___Don’t know

E12. What age was your last period?

___ years

___Don’t know

E12a. During the period when you had periods, what was your usual period flow?

___Light→ go to Question 16

___Medium→ go to Question 16

___Heavy→ go to Question 16

___Don’t know→ go to Question 16

E13. When was your last period before this study blood draw?

Date:______________

___Don’t know

E14. How many days has been your cycle on average during the last year?

___>26 days

___27-29 days

___30-32

___>32 days

___Don’t know

E15. Can you characterize your usual period flow during the last year?

___Light

___Medium

___Heavy

___Don’t know

E16. Have you ever been pregnant?

___Yes

___No → go to Section F

___Don’t know

E17. How many times have you been pregnant in your life?

_______ times

E18. Now I’d like to get more information about each of your pregnancies. Let’s start with your most recent pregnancy. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

	Pregnancy 1	Pregnancy 2	Pregnancy 3	Pregnancy 4
a. What month and year did this pregnancy start?	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _
b. What month and year did this pregnancy end?	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _
c. Did the pregnancy result in a live birth?	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know
d. Did you breastfed this child/these children?	Yes No → go to k. Don’t know	Yes No → go to k. Don’t know	Yes No → go to k. Don’t know	Yes No → go to k. Don’t know
e. How long did you breastfeed [this child/these children]?	__ months	__ months	__ months	__ months
f. When did you stop breastfeeding this child/these children?	__month ____ year	__month ____ year	__month ____ year	__month ____ year
g. Did a doctor or nurse say that you had pre-eclampsia during your pregnancy?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
h. Did a doctor or nurse say that you had pregnancy-induced hypertension?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
i. Did a doctor or nurse say that you had gestational diabetes?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know

Section F: Social History

The following questions ask about smoking and alcohol use.

F1. Have you ever smoked cigarettes?

___Yes

___No → go to Question F7

F2. Do you currently smoke cigarettes?

___Yes

___No → go to Question F5

F3. On average, how many cigarettes do you smoke a day? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day

F4. In total, how many years have you smoked, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Question F7

F5. How many years did you smoke before you quit?

___years

___ Don’t know

F5a. How long ago did you quit?

___Less than 5 years ago

___5-9 years ago

___More than 10 years ago

___Don’t know

F6. On average, when you were smoking, about how many cigarettes per day did you smoke? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day

F7. Have you ever used any other tobacco products (such as chewing tobacco, smokeless tobacco, cigars, a pipe, etc.)?

___Yes

___No → go to Question F10

F8. Do you currently use any of these tobacco products?

___Yes

___No

F9. Have you ever drunk alcoholic beverages? (This includes beer, wine, wine coolers, hard

lemonade, and spirits.)

___Yes

___No → go to Section G

F10. Do you currently drink alcoholic beverages? (This includes beer, wine, wine coolers, hard lemonade, and spirits.)

___Yes

___No → go to Section G.

F11. On average, how often do you drink alcoholic beverages?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month

F12. When you drink, how many servings of alcohol do you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings

F13. In total, how many years have you drank, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Section G

F14. When you were consuming alcoholic beverages, how often did you drink on average?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month

F15. When you drank, how many servings of alcohol did you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings

F16. In total, how many years did you drink? Enter ‘00’ if less than 1 year.

____ years

F17. How long ago did you quit?

___Less than 5 years ago

___More than 5 years ago

___Don’t know

Section G: Family Medical History

G1. Do any of your blood relatives - children, parents, or siblings - currently have cancer or have they had cancer? We are only asking about family members who are blood relatives: children, parents, and siblings.

___Yes

___No → go to Question G4

G2. In all, how many family members (not including yourself) have had (or now have) cancer?

___number

___Don’t know

G3. Now I’d like to get more information about each of your relatives who had/has cancer. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Complete the information for the first relative completely before asking about the next relative. Once information about all blood relatives with cancer has been collected, go to Question G4.

	First relative	Second relative	Third relative	Fourth relative
a. Was this relative a . . .	Child Parent Sibling	Child Parent Sibling	Child Parent Sibling	Child Parent Sibling
b. What type of cancer did this relative have
c. Is this relative	Living Deceased	Living Deceased	Living Deceased	Living Deceased
d. What year was your relative diagnosed with cancer?	_ _ _ _ Don’t know	_ _ _ _ Don’t know	_ _ _ _ Don’t know	_ _ _ _ Don’t know

G4. Have any of your blood relatives (that is children, parents, or siblings) ever been told by a health professional that they have or had any of the following conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical condition		If yes, ask: Which relative had this condition?
Thyroid disease?	Yes (Please specify) ______________________ No Don’t know	Child Parent Sibling
High cholesterol?	Yes No Don’t know	Child Parent Sibling
High blood pressure? (not including pregnancy induced hypertension)	Yes No Don’t know	Child Parent Sibling
Heart Disease?	Yes No Don’t know	Child Parent Sibling
Osteoarthritis?	Yes No Don’t know	Child Parent Sibling
Osteoporosis?	Yes No Don’t know	Child Parent Sibling
Endometriosis?	Yes No Don’t know	Child Parent Sibling
Liver disease?	Yes (Please specify) ______________________ No Don’t know	Child Parent Sibling
Kidney disease?	Yes (Please specify) _____________________ No Don’t know	Child Parent Sibling
Ulcerative colitis?	Yes No Don’t know	Child Parent Sibling
Rheumatoid arthritis?	Yes No Don’t know	Child Parent Sibling
Lupus?	Yes No Don’t know	Child Parent Sibling
Multiple sclerosis?	Yes No Don’t know	Child Parent Sibling
Diabetes (not related to pregnancy)?	Yes (Please specify) _____________________ No Don’t know	Child Parent Sibling
Asthma?	Yes No Don’t know	Child Parent Sibling
Parkinson Disease?	Yes No Don’t know	Child Parent Sibling
Chronic bronchitis?	Yes No Don’t know	Child Parent Sibling
Emphysema?	Yes No Don’t know	Child Parent Sibling
Fibromyalgia?	Yes No Don’t know	Child Parent Sibling
Celiac Disease?	Yes No Don’t know	Child Parent Sibling
Crohn’s Disease?	Yes No Don’t know	Child Parent Sibling
Scleroderma?	Yes No Don’t know	Child Parent Sibling
Atopic dermatitis/eczema?	Yes (Please specify) _____________________ No Don’t know	Child Parent Sibling
Allergies?	Yes (Please specify) _____________________ No Don’t know	Child Parent Sibling
Infertility?	Yes No Don’t know	Child Parent Sibling

CONCLUSION: That completes this survey. I would like to sincerely thank you for your time.

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