**CHILDHOOD LEUKEMIA STUDY**

# SECTION L: HOUSEHOLD EXPOSURES

L13. Starting at one month prior to your pregnancy with...up to
\_\_\_\_\_\_\_\_\_\_\_\_\_ did you have any family pets?

L14. What type of pets were they? READ LIST

L14a. Dog Yes 1 If yes, date \_\_\_/\_\_\_ \_\_\_/\_\_\_

No 2 started stopped

L14b. Cat Yes 1 If yes, date \_\_\_/\_\_\_ \_\_\_/\_\_\_

No 2 started stopped

L14c. Bird Yes 1 If yes, date \_\_\_/\_\_\_ \_\_\_/\_\_\_

No 2 started stopped

L14d. Other Yes 1 If yes, date \_\_\_/\_\_\_ \_\_\_/\_\_\_

No 2 started stopped

L15. Did any of these pets have a disease that was diagnosed by a
veterinarian?

Yes 1

No 2

DK 9

IF YES specify which pets and describe the illness

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

During your pregnancy with ..., did you use any of the following?

+-------------+-------------+-------------+-------------+-------------+
|             |             | a\. Did you | b\. How     | c\. How     |
|             |             | usually use | many hours  | many months |
|             |             | it on a     | each night  | did you use |
|             |             | high,       | did you     | it?         |
|             |             | medium, or  | usually use |             |
|             |             | low         | it?         |             |
|             |             | setting?    |             |             |
+-------------+-------------+-------------+-------------+-------------+
| L16.        | Yes 1       | High 1      | \_          | \_          |
| Electric    |             |             | \_\_\_\_\_\ | \_\_\_\_\_\ |
| Blanket     | No 2        | Medium 2    | _\_\_\_\_\_ | _\_\_\_\_\_ |
|             |             |             |             |             |
|             | DK 9        | Low 3       | \# HOURS    | \# MONTHS   |
|             |             |             |             |             |
|             |             | DK 9        |             |             |
+-------------+-------------+-------------+-------------+-------------+
| L17.        | Yes 1       | High 1      | \_          | \_          |
| Electric    |             |             | \_\_\_\_\_\ | \_\_\_\_\_\ |
| Water Bed   | No 2        | Medium 2    | _\_\_\_\_\_ | _\_\_\_\_\_ |
| Heater      |             |             |             |             |
|             | DK 9        | Low 3       | \# HOURS    | \# MONTHS   |
|             |             |             |             |             |
|             |             | DK 9        |             |             |
+-------------+-------------+-------------+-------------+-------------+
| L18.        | Yes 1       | High 1      | \_          | \_          |
| Electric    |             |             | \_\_\_\_\_\ | \_\_\_\_\_\ |
| Mattress    | No 2        | Medium 2    | _\_\_\_\_\_ | _\_\_\_\_\_ |
| Pad         |             |             |             |             |
|             | DK 9        | Low 3       | \# HOURS    | \# MONTHS   |
|             |             |             |             |             |
|             |             | DK 9        |             |             |
+-------------+-------------+-------------+-------------+-------------+

+------------+----------------------------+----------------------------+
|            | a.  At the time of your    | b.  During                 |
|            |     pregnancy with...      |     \_                     |
|            |                            | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            |                            |                            |
|            |                            | (reference year)           |
+------------+----------------------------+----------------------------+
| L19. What  | Single family residence 1  | Single family residence 1  |
| type of    |                            |                            |
| housing    | Mobile home 2              | Mobile home 2              |
| did you    |                            |                            |
| live in?   | Duplex -- Quadraplex (2-4  | Duplex -- Quadraplex (2-4  |
|            | units) 3                   | units) 3                   |
|            |                            |                            |
|            | Apartment with 5-10 units  | Apartment with 5-10 units  |
|            | 4                          | 4                          |
|            |                            |                            |
|            | Apartment with 11+ units 5 | Apartment with 11+ units 5 |
|            |                            |                            |
|            | Other                      | Other                      |
|            | (SPECIFY)\_\_              | (SPECIFY)\_\_              |
|            | \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            |                            |                            |
|            | \_\_\_                     | \_\_\_                     |
|            | \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            | \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            | 6                          | 6                          |
|            |                            |                            |
|            | DK 9                       | DK 9                       |
+------------+----------------------------+----------------------------+
| L20. What  | Electric 1                 | Electric 1                 |
| type of    |                            |                            |
| heating    | Gas 2                      | Gas 2                      |
| system did |                            |                            |
| you have?  | Oil 3                      | Oil 3                      |
|            |                            |                            |
|            | Coal 4                     | Coal 4                     |
|            |                            |                            |
|            | Wood 5                     | Wood 5                     |
|            |                            |                            |
|            | Other                      | Other                      |
|            | (SPECIFY)\_\_              | (SPECIFY)\_\_              |
|            | \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            |                            |                            |
|            | \_\_\_\                    | \_\_\_\                    |
|            | _\_\_\_\_\_\_\_\_\_\_\_\_\ | _\_\_\_\_\_\_\_\_\_\_\_\_\ |
|            | _\_\_\_\_\_\_\_\_\_\_\_\_6 | _\_\_\_\_\_\_\_\_\_\_\_\_6 |
|            |                            |                            |
|            | DK 9                       | DK 9                       |
+------------+----------------------------+----------------------------+
| L21. What  | Community source 1         | Community source 1         |
| type of    |                            |                            |
| water      | Household well 2           | Household well 2           |
| supply did |                            |                            |
| you use?   | Bottled water 3            | Bottled water 3            |
|            |                            |                            |
|            | Other (SPECIFY)            | Other (SPECIFY)            |
|            | \_\_                       | \_\_                       |
|            | \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_ |
|            |                            |                            |
|            | \_\_\_\                    | \_\_\_\                    |
|            | _\_\_\_\_\_\_\_\_\_\_\_\_\ | _\_\_\_\_\_\_\_\_\_\_\_\_\ |
|            | _\_\_\_\_\_\_\_\_\_\_\_\_6 | _\_\_\_\_\_\_\_\_\_\_\_\_6 |
|            |                            |                            |
|            | DK 9                       | DK 9                       |
+------------+----------------------------+----------------------------+
| L22. Did   | Yes 1                      | Yes 1                      |
| you use    |                            |                            |
| incense?   | No 2                       | No 2                       |
|            |                            |                            |
|            | DK 9                       | DK 9                       |
|            |                            |                            |
|            | IF YES                     | IF YES                     |
|            |                            |                            |
|            | D                          | D                          |
|            |                            |                            |
|            | How often?                 | How often?                 |
|            | \_\_\_\_\_\_\_\_\_\_\_ per | \_\_\_\_\_\_\_\_\_\_\_ per |
|            | W                          | W                          |
|            |                            |                            |
|            | \# TIMES M                 | \# TIMES M                 |
|            |                            |                            |
|            | Y                          | Y                          |
+------------+----------------------------+----------------------------+

NOW I'M GOING TO ASK ABOUT SOME PRODUCTS YOU MAY HAVE USED OR COME IN
CONTACT WITH AT HOME IN THE MONTH BEFORE OR DURING THE PREGNANCY (OR
WHILE NURSING). PLEASE TURN TO PAGE 10, LIST H OF THE INTERVIEW GUIDE
AND FOLLOW ALONG.

+----------------+----------+-------------+----------------+----------+
| a\. In the     |          | b\. How     | c\. When did   | d\. name |
| month before   |          | frequently  | you come in    | of       |
| the pregnancy, |          | did you     | contact with   | product  |
| during the     |          | come in     | \_\_\_\_\      | and      |
| pregnancy, or  |          | contact     | _\_\_\_\_\_\_? | details  |
| while nursing, |          | with        |                |          |
| did you come   |          | \_\_\_\_\_  |                |          |
| in contact     |          | \_\_\_\_\_? |                |          |
| with products  |          |             |                |          |
| used to        |          | READ        |                |          |
| control:       |          | CHOICES     |                |          |
+----------------+----------+-------------+----------------+----------+
| L23. Ants,     | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| cockroaches,   |          | _\_\_\_\_\_ |                |          |
| flies, or bees | No 2     |             | T1 3           |          |
|                | (L24)    | times per   |                |          |
| Such as Raid,  |          |             | T2 4           |          |
| Black Flag bug | DK 9     | Day D       |                |          |
| spray, Ortho   | (L24)    |             | T3 5           |          |
| Hornet and     |          | Week W      |                |          |
| Wasp Killer,   |          |             | Nursing 6      |          |
| no-pest        |          | Month M     |                |          |
| strips, ant    |          |             | DK 9           |          |
| traps, or      |          | Year Y      |                |          |
| roach baits?   |          |             |                |          |
+----------------+----------+-------------+----------------+----------+
| L24. Moths     | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
|                |          | _\_\_\_\_\_ |                |          |
| Such as        | No 2     |             | T1 3           |          |
| mothballs?     | (L25)    | times per   |                |          |
|                |          |             | T2 4           |          |
|                | DK 9     | Day D       |                |          |
|                | (L25)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L25. Spiders   | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| or mites       |          | _\_\_\_\_\_ |                |          |
|                | No 2     |             | T1 3           |          |
| Such as        | (L26)    | times per   |                |          |
| Defend?        |          |             | T2 4           |          |
|                | DK 9     | Day D       |                |          |
|                | (L26)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L26. Mice,     | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| rats, gophers, |          | _\_\_\_\_\_ |                |          |
| or moles       | No 2     |             | T1 3           |          |
|                | (L27)    | times per   |                |          |
| Such as D-con  |          |             | T2 4           |          |
| or Warfarin?   | DK 9     | Day D       |                |          |
|                | (L27)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L27. Fleas or  | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| ticks          |          | _\_\_\_\_\_ |                |          |
|                | No 2     |             | T1 3           |          |
| Such as        | (L28)    | times per   |                |          |
| Holiday,       |          |             | T2 4           |          |
| Four-Gone      | DK 9     | Day D       |                |          |
| Foggers, or    | (L28)    |             | T3 5           |          |
| Flea collars   |          | Week W      |                |          |
| for pets?      |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+

+----------------+----------+-------------+----------------+----------+
| a\. In the     |          | b\. How     | c\. When did   | d\. name |
| month before   |          | frequently  | you come in    | of       |
| the pregnancy, |          | did you     | contact with   | product  |
| during the     |          | come in     | \_\_\_\_\      | and      |
| pregnancy, or  |          | contact     | _\_\_\_\_\_\_? | details  |
| while nursing, |          | with        |                |          |
| did you come   |          | \_\_\_\_\_  |                |          |
| in contact     |          | \_\_\_\_\_? |                |          |
| with products  |          |             |                |          |
| used to        |          | READ        |                |          |
| control:       |          | CHOICES     |                |          |
+----------------+----------+-------------+----------------+----------+
| L28. Termites  | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
|                |          | _\_\_\_\_\_ |                |          |
| Such as        | No 2     |             | T1 3           |          |
| Chlordane?     | (L29)    | times per   |                |          |
|                |          |             | T2 4           |          |
|                | DK 9     | Day D       |                |          |
|                | (L29)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L29. Slugs or  | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| snails         |          | _\_\_\_\_\_ |                |          |
|                | No 2     |             | T1 3           |          |
| Such as slug   | (L30)    | times per   |                |          |
| and snail      |          |             | T2 4           |          |
| bait?          | DK 9     | Day D       |                |          |
|                | (L30)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L30. Weeds     | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
|                |          | _\_\_\_\_\_ |                |          |
| Such as        | No 2     |             | T1 3           |          |
| dandelion      | (L31)    | times per   |                |          |
| killers or     |          |             | T2 4           |          |
| carbgrass      | DK 9     | Day D       |                |          |
| killers?       | (L31)    |             | T3 5           |          |
|                |          | Week W      |                |          |
|                |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+
| L31.           | Yes 1    | \_\_\_\_\   | Mo. Before 2   |          |
| Plant/tree     |          | _\_\_\_\_\_ |                |          |
| insects or     | No 2     |             | T1 3           |          |
| diseases       | (L32)    | times per   |                |          |
|                |          |             | T2 4           |          |
| Such as Sevin, | DK 9     | Day D       |                |          |
| Malathion,     | (L32)    |             | T3 5           |          |
| Rose Dust, or  |          | Week W      |                |          |
| Tomato Dust?   |          |             | Nursing 6      |          |
|                |          | Month M     |                |          |
|                |          |             | DK 9           |          |
|                |          | Year Y      |                |          |
+----------------+----------+-------------+----------------+----------+

+----------------+-----------+------------+----------------+----------+
|                | a\.       | b\. How    | c\. When did   | d\. name |
|                |           | frequently | you come in    | of       |
|                |           | did you    | contact with   | product  |
|                |           | come in    | \_\_\_\_\      | and      |
|                |           | contact    | _\_\_\_\_\_\_? | details  |
|                |           | with       |                |          |
|                |           | \          |                |          |
|                |           | _\_\_\_\_\ |                |          |
|                |           | _\_\_\_\_? |                |          |
|                |           |            |                |          |
|                |           | READ       |                |          |
|                |           | CHOICES    |                |          |
+----------------+-----------+------------+----------------+----------+
| L32. Was your  | Yes 1     | \_\_\_\_\_ | Mo. Before 2   |          |
| house treated  |           | \_\_\_\_\_ |                |          |
| by             | No 2      |            | T1 3           |          |
| exterminators  | (L33)     | times per  |                |          |
| in the month   |           |            | T2 4           |          |
| before the     | DK 9      | Day D      |                |          |
| pregnancy,     | (L33)     |            | T3 5           |          |
| during the     |           | Week W     |                |          |
| pregnancy, (or |           |            | Nursing 6      |          |
| while          |           | Month M    |                |          |
| nursing)?      |           |            | DK 9           |          |
|                |           | Year Y     |                |          |
+----------------+-----------+------------+----------------+----------+
| L33. Did you   | Yes 1     | \_\_\_\_\_ | Mo. Before 2   |          |
| come in        |           | \_\_\_\_\_ |                |          |
| contact with   | No 2      |            | T1 3           |          |
| any paints,    | (L34)     | times per  |                |          |
| stains or      |           |            | T2 4           |          |
| lacquers in    | DK 9      | Day D      |                |          |
| this time?     | (L34)     |            | T3 5           |          |
|                |           | Week W     |                |          |
|                |           |            | Nursing 6      |          |
|                |           | Month M    |                |          |
|                |           |            | DK 9           |          |
|                |           | Year Y     |                |          |
+----------------+-----------+------------+----------------+----------+
| L34. Did you   | Yes 1     | \_\_\_\_\_ | Mo. Before 2   |          |
| come in        |           | \_\_\_\_\_ |                |          |
| contact with   | No 2      |            | T1 3           |          |
| petroleum      | (L35)     | times per  |                |          |
| products such  |           |            | T2 4           |          |
| as gasoline,   | DK 9      | Day D      |                |          |
| kerosene,      | (L35)     |            | T3 5           |          |
| lubricating    |           | Week W     |                |          |
| oils, or spot  |           |            | Nursing 6      |          |
| removers in    |           | Month M    |                |          |
| this time      |           |            | DK 9           |          |
| period?        |           | Year Y     |                |          |
+----------------+-----------+------------+----------------+----------+
| L35. Did you   | Yes 1     | \_\_\_\_\_ | Mo. Before 2   |          |
| use any hair   |           | \_\_\_\_\_ |                |          |
| dyes or tints  | No 2      |            | T1 3           |          |
| during this    | (NEXT     | times per  |                |          |
| time?          | SECTION)  |            | T2 4           |          |
|                |           | Day D      |                |          |
|                | DK 9      |            | T3 5           |          |
|                | (NEXT     | Week W     |                |          |
|                | SECTION)  |            | Nursing 6      |          |
|                |           | Month M    |                |          |
|                |           |            | DK 9           |          |
|                |           | Year Y     |                |          |
+----------------+-----------+------------+----------------+----------+