Attachment H


Example Questionnaire



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Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx






Sample questionnaire introduction for investigation that includes collecting questionnaire data and environmental samples:

Thank you for taking our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR ENVIRONMENTAL-air, soil, water, foods testing] Once we are done with this investigation, you will be given a copy of the testing results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.



Sample questionnaire introduction for investigation that includes collecting questionnaire data and biologic specimens:

Thank you for taking part in our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR BIOLOGIC-blood, urine, hair, nails, other testing for you]. Once we are done with this investigation, you will be given a copy and details of your test results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.












CDC estimates the average public reporting burden for this collection of information as 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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, Ga. 30333; ATTN: PRA (0920-xxxx).



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Interviewer Name: ________________________ Interview Location: _______________________________

Participant ID: _______________________ Date of Interview: _________/________/______ (month/day/year)







Phone (____) _________________________





Participant Name: ________________________________________________

Mailing Address: ________________________________________________

City: _____________________ Zip code: ________________


Physical Address: ________________________________________________

City: _____________________ Zip code: ________________


GPS (at well head): _____________________


Sociodemographics

  1. How old are you (in years)? ________


  1. What is your sex?


  1. Please tell us how many people in your household (including yourself) are in the following age categories:

Age Category

How many in the household

Less than 2 years old


2 years-17 years old


18 years-64 years old


More than 64 years old



  1. What is the highest grade of school that you completed?

  1. Before taxes, what is your total yearly household income?


  1. What is your ethnicity?


  1. What is your race?


Household water source

  1. How long have you lived in your home?

________________ (months/years)

Refused

  1. How would you describe the physical condition of your well (including your well pump and well casing, or the tube that is placed in the drilled hole to maintain the well opening)?


  1. How deep is your well? ______________ ft  Don’t know  Refused


  1. How old is your well? ______________ ft  Don’t know  Refused



  1. During the past year, have you ever had a problem with your well providing insufficient water for household uses?


  1. During the past year, have you ever had any concerns with the quality of your well water?








Household water use

  1. How many 8 oz. glasses of water (including water for making other beverages, such as coffee or orange juice) have you drunk from your well in the last 24 hours?: ______ glasses


  1. In the past week, where do you usually get your drinking and cooking water? [Rank order, 1=most and 4=least]



  1. When at home, what is the main reason that you drink water from sources other than your well?


  1. When you cook with water, how often do you use the tap water from your private well? (e.g., soups, pasta, rice, etc.)?

  1. Do you use any of the following water filters in your home? Check all that apply.

17a. If you use a filter in your home, do you regularly replace and maintain the filters?



Exposure information

  1. What kind of work do you do (for example, registered nurse, computer specialist, cashier, auto

mechanic, etc.)? ______________________________________________________________________________

  1. What kind of business or industry do you work in (for example, hospital, elementary school,

laboratory, clothing manufacturing, restaurant, etc.)? ______________________________________________________________________________

  1. Have you eaten or drunk any of the following in the past 3 days?


a. Fish (including fresh fish, fish sticks, canned tuna fish, fish sandwiches, etc.)

Yes

No

b. Shellfish (shrimp, oyster, crab, etc)

Yes

No

c. Rice

Yes

No

d. Homeopathic, home, folk, or natural remedies

Yes

No


  1. Have you used any pesticides including animal repellant, fungicide, herbicide, insecticide, etc. to get rid of insects, rodents, weeds, or other pests in the past 3 days?

22a. If yes, was that done inside your home, outside your home, or both?



  1. What hobbies, excluding sports, (for example, ceramics, jewelry making, painting), do you have? _____________________________________________________________________________



  1. Do you smoke?


  1. Has anyone smoked tobacco (such as cigarettes) in the home in the last 3 days?



Health status

  1. How would you describe your overall health?


  1. Do you have any of the following medical problems?


  1. Do you have any health concerns about drinking your well water?


  1. If yes, what are your health concerns? Check all that apply.


  1. Have you ever been diagnosed by a healthcare provider with an illness they attributed to drinking well water?



  1. During the past year, have you ever been worried about the quantity of water your well provided for household uses?



  1. During the past year, have you ever been worried about the quality of your well water?



Perceptions and practices that could impact an individual’s exposure level

  1. In your opinion, how would you rate the following characteristics of your well water?

Taste: Very good Good Neutral Bad Really bad

Smell: Very good Good Neutral Bad Really bad

Appearance: Very good Good Neutral Bad Really bad

Safety: Very good Good Neutral Bad Really bad

  1. When was the last time your well water was tested?

  1. The last time your well water was tested, what did you test for? Check all that apply.



  1. Have you ever received the results of the testing?


35a. If yes, what did the results tell you about your well water quality?:____________________

35b. If yes, what actions did you take as a result of receiving your well results?:________________

  1. I should test my well to make sure that my water is safe.

  1. I would be more likely to test my well if I received a public notice from the county/state about water contamination in my neighborhood.

  1. I would be more likely to test my well if I knew what contaminants to test for.



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