Document ID: EPA-HQ-ORD-2005-0010-0032
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2008-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
24
Partner
Questionnaire
Six
Month
Home
Visit
Eligibility:
All
partners
of
women
who
gave
birth
Mode
of
administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
20
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:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Partner
6
Month
(
Instrument
#
24)

1
PRELOADED
DATA:

Today's
date
Language
of
interview
(
English/
Spanish)

Female
Name
Female
Address
and
Phone
Spouse/
Partner's
Name
Spouse/
Partner's
Address
and
Phone
Marital
status
Occupation
Chemical
exposures
Student
status
QUESTIONNAIRE:
Partner
6
Month
(
Instrument
#
24)

2
Address
(
update)

1.
I'd
just
like
to
quickly
confirm
the
contact
information
we
have
on
file:
{
FILL
PRELOADED
ADDRESS
AND
PHONE
NUMBER}.
Is
this
still
correct?

1
YES
2
NO

Enter
correct
information
{
END
OF
ADDRESS
MODULE}
Partner
6
Month
(
Instrument
#
24)

3
Occupation
(
Update)

1.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL:
not
a
/
a
full­
time
/
a
parttime
student.
Is
this
still
correct?

1
YES

SKIP
TO
Q4
2
NO
2..
Are
you
now
a
student
full
or
part­
time?

1
YES,
FULL­
TIME
2
YES,
PART­
TIME
3
NO,
NOT
A
STUDENT

SKIP
TO
Q4
3.
What
type
of
school
are
you
currently
attending?

1
HIGH
SCHOOL
2
TECHNICAL
SCHOOL
3
COLLEGE
OR
UNIVERSITY
4
GRADUATE
SCHOOL
5
PROFESSIONAL
SCHOOL
(
FOR
EXAMPLE,
MEDICAL
SCHOOL)
6
OTHER
(
SPECIFY)_________________

4.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL
EMPLOYMENT).
Is
this
still
correct?

1
YES
2
NO

SKIP
TO
Q5
Q4=
YES,
STILL
WORKING

SKIP
TO
Q6
Q4=
YES,
STILL
LOOKING
FOR
WORK

GO
TO
NEXT
MODULE
Q4=
YES,
STILL
NOT
WORKING

GO
TO
NEXT
MODULE
5.
Are
you
currently 

[
ONLY
DISPLAY
THE
OPTIONS
NOT
SELECTED
IN
PREVIOUS
INTERVIEW]
1
Working
at
a
job
or
business,
SKIP
TO
PARAGRAPH
BEFORE
Q7
2
Looking
for
work,
or
GO
TO
NEXT
MODULE
3
Not
working
at
a
job
or
business?
GO
TO
NEXT
MODULE
6.
Did
you
start
work
at
any
jobs
since
[
FILL
DATE]?

1
YES
2
NO

GO
TO
NEXT
MODULE
Partner
6
Month
(
Instrument
#
24)

4
Please
tell
me
about
the
jobs
you've
had
since
your
last
interview,
starting
with
the
(
FILL:
current/
most
recent/
next)
one.

7.
On
what
date
did
you
start
this
job?

MM/
DD/
YYYY
8.
On
what
date
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
9.
What
kind
of
business
or
industry
(
FILL:
is/
was)
this?
(
For
example:
TV
and
radio
management,
retail
shoe
store,
state
labor
department,
farm.)

_________________________________
ENTER
NAME
OF
BUSINESS,
JOB,
OR
INDUSTRY
10.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
11.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
12.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q14
13.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
14.
Did
you
have
any
other
jobs
since
[
FILL
DATE]?

1
YES
[
REPEAT
Q67­
Q13
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Partner
6
Month
(
Instrument
#
24)

5
Chemical
Exposures
(
Update)

Now
I'm
going
to
ask
you
about
chemicals
you
may
have
used
at
work,
at
home,
or
for
any
hobbies.

1.
Last
time
you
said
you
were
{
FILL:
not
exposed
to
any
of
these
chemicals
/
exposed
to
[
DISPLAY
LIST
OF
EXPOSURES
REPORTED
IN
PREVIOUS
VISIT]}.
Is
this
still
correct?
(
HAND
SHOW
CARD
TO
RESPONDENT
AND
READ
THE
LETTER
CORRESPONDING
TO
EACH
PREVIOUS
EXPOSURE)

1
YES

IF
NO
PREVIOUS
EXPOSURES,
SKIP
TO
END
2
NO
2.
[
IF
Q1=
1,
ASK:]
Are
you
currently
also
exposed
to
any
of
the
following
chemicals?
[
IF
Q1=
2,
ASK:]
Which
of
the
following
chemicals
are
you
currently
exposed
to?

[
IF
Q1=
1,
DISPLAY
ONLY
THOSE
EXPOSURES
NOT
PREVIOUSLY
REPORTED.
IF
Q1=
2,
DISPLAY
ALL
EXPOSURES]

YES
NO

SKIP
TO
NEXT
EXPOSURE
3.
How
often
are
you
exposed
to
[
INSERT
EXPOSURE]
?
Would
you
say.
.
.

4.
Did
the
exposure
occur
while
you
were
at
work?

2.
Currently
Exposed
Yes
=
01
No
=
02
3.
Frequency
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
4.
At
work
Yes
=
01
No
=
02
A.
Fuels,
solvents,
dry
cleaning
fluids,
degreasers,
or
adhesives
B.
Lead,
including
paints
with
lead
in
them
C.
Fumes
or
gases
(
e.
g.,
nitrous
oxide,
ethylene
oxide,
anesthetic
gases)
D.
Radiation
(
e.
g.,
fluoroscopy,
radioisotopes,
highintensity
microwaves,
x­
rays)
E.
Mercury
F.
Metal
fumes
or
particles
G.
Pesticides
that
you've
mixed
or
applied
H.
Paints,
strippers,
or
varnishes
I.
Hair
and
nail
products
(
e.
g,
hair
dye,
bleach,
hair
relaxer,
nail
polish
and
remover)
J.
Cleaning
products
(
e.
g.,
oven
cleaner,
disinfectant,
carpet
cleaner,
bleach)
K.
Carbon
black
from
copying
machines
L.
Coal
or
coal
products
from
hot
asphalt,
tar,
or
roofing
material
{
END
OF
CHEMICAL
EXPOSURES
MODULE}
Partner
6
Month
(
Instrument
#
24)

6
Activity
(
Full)

Now
I
am
going
to
ask
you
some
questions
about
physical
activities
you
might
do
at
work,
at
home,
for
recreation,
and
about
activities
involving
child
or
adult
care.
I
want
you
to
tell
me
about
activities
you
did
in
the
past
month
that
caused
at
least
some
increase
in
breathing
and
heart
rate.

1.
In
the
past
month,
did
you 
2.
IF
YES:
On
average
over
the
past
month,
how
many
times
did
you
do
these
activities?
Would
you
say 
3.
Thinking
about
your
breathing
and
heart
rate,
how
hard
did
this
usually
feel
to
you?
Did
it
feel 
(
HAND
SHOW
CARD
TO
RESPONDENT)
A.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
participate
in
any
work
activities,
such
as
walking,
lifting,
or
carrying
objects
or
people,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
B.
participate
in
any
non­
work,
recreational
activity
or
exercise,
such
as
walking
for
exercise,
swimming,
or
dancing,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
C.
participate
in
any
outdoor
household
activities,
such
as
gardening,
mowing,
or
raking,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
D.
participate
in
any
indoor
household
activities,
such
as
scrubbing
floors,
mopping,
laundry,
or
vacuuming,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
E.
participate
in
any
child
or
adult
care
activities
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
These
would
be
activities
such
as
playing
with
children,
pushing
a
stroller
or
wheelchair,
carrying,
or
lifting
a
child
or
adult.
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
F.
walk
for
transportation,
such
as
to
work
or
to
the
store,
and
that
walking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
G.
bike
for
transportation,
such
as
to
work
or
to
the
store,
and
that
biking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
FH
=
Fairly
hard
(
at
least
some
increase
in
breathing
and
heart
rate),
SH
=
Somewhat
hard
(
moderate
increase
in
breathing
and
heart
rate),
or
H
=
Hard
or
very
hard
(
large
increase
in
breathing
and
heart
rate)?
Partner
6
Month
(
Instrument
#
24)

7
Now
think
about
the
activities
you
did
in
the
past
week 

1.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
In
the
past
week,
would
you
say
your
work
activities
were
usually 

1
Not
hard
=
did
not
feel
any
increase
in
breathing
or
heart
rate
2
Fairly
light
=
at
least
some
increase
in
breathing
and
heart
rate
3
Somewhat
hard
=
moderate
increase
in
breathing
and
heart
rate
4
Hard
or
very
hard
=
large
increase
in
breathing
and
heart
rate
5.
Think
about
how
active
you
were
during
your
non­
working
and
recreational
hours
in
the
past
week.
Would
you
say
your
activities
were
usually 

1
not
hard
=
you
did
not
feel
any
increase
in
breathing
or
heart
rate
2
fairly
light
=
you
had
at
least
some
increase
in
breathing
and
heart
rate
3
somewhat
hard
=
you
had
a
moderate
increase
in
breathing
and
heart
rate
4
hard
or
very
hard
=
you
had
a
large
increase
in
breathing
and
heart
rate
Now
I
will
ask
you
to
think
about
your
typical
daily
activities
during
the
past
month.

6.
Please
tell
me
which
of
these
four
sentences
best
describes
your
usual
daily
activities
over
the
past
month?
(
INTERVIEWER
PROBE:
Daily
activities
may
include
your
work,
housework,
errands,
and
anything
else
you
normally
do
throughout
a
typical
day.)

1
You
sit
during
the
day
and
do
not
walk
about
very
much
2
You
stand
or
walk
about
quite
a
lot
during
the
day,
but
do
not
have
to
carry
or
lift
things
very
often
3
You
lift
or
carry
light
loads,
or
have
to
climb
stairs
or
hills
often
4
You
do
heavy
work
or
carry
heavy
loads
7.
Over
the
past
month,
on
a
typical
day
how
much
time
altogether
did
you
spend
sitting
and
watching
TV
or
videos
or
using
a
computer
outside
of
work?
Would
you
say
.
.
.

0
Less
than
1
hour
1
1
hour
2
2
hours
3
3
hours
4
4
hours
5
5
hours
or
more
6
You
do
not
watch
TV
or
videos
or
use
a
computer
outside
of
work
8.
How
does
the
amount
of
activity
that
you
reported
for
the
past
month
compare
with
your
physical
activity
for
the
past
12
months?
Over
the
past
month,
were
you
.
.
.

1
More
active
2
Less
active
3
About
the
same
Partner
6
Month
(
Instrument
#
24)

8
9.
Compared
with
most
men
your
age,
would
you
say
that
you
are
.
.
.

1
More
active
2
Less
active
3
About
the
same
[
ASK
Q21
IF
MAN
AGE
>=
30]
10.
Compared
with
yourself
10
years
ago,
would
you
say
that
you
are
.
.
.

1
More
active
now
2
Less
active
now
3
About
the
same
{
END
OF
ACTIVITY
MODULE}
Partner
6
Month
(
Instrument
#
24)

9
Personal
Medical
History
(
Update)

Now
I'd
like
to
ask
you
about
any
changes
to
your
general
health.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
developed
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

[
CAPI:
ONLY
DISPLAY
ITEMS
=
NO
FOR
LAST
INTERVIEW]

1
High
blood
pressure
or
hypertension
2
High
blood
sugar
or
diabetes
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
6
Hayfever
or
allergy
7
Skin
allergy
or
eczema
8
Asthma
IF
Q1
=
8,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
tell
you
that
you
have
asthma?

1
YES
2
NO

SKIP
TO
Q5
3.
Have
you
used
any
inhalers
or
taken
any
pills
for
asthma
or
wheezing
or
whistling
in
your
chest?

1
YES
2
NO
4.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
5.
Since
your
last
interview
on
[
FILL
DATE],
have
you
been
diagnosed
with
any
other
serious
illnesses
that
I
haven't
asked
about?

1
YES
2
NO

GO
TO
NEXT
MODULE
5a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

6.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

GO
TO
NEXT
MODULE
Partner
6
Month
(
Instrument
#
24)

10
6a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

__________________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Partner
6
Month
(
Instrument
#
24)

11
Alcohol
(
update)

The
next
few
questions
are
about
alcohol
consumption.
A
"
drink"
is
a
can
or
bottle
of
beer,
a
glass
of
wine
or
a
wine
cooler,
a
shot
of
liquor,
or
a
mixed
drink
with
liquor
in
it.
We
are
not
asking
about
times
when
you
only
had
a
sip
or
two
from
a
drink.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
had
any
alcoholic
drinks?

1
YES
2
NO

GO
TO
NEXT
MODULE
2.
Since
your
last
interview
on
[
FILL
DATE],
how
many
alcoholic
drinks
did
you
have
in
an
average
week?
Would
you
say 

1
Less
than
1
drink
a
week,
2
1
to
3
drinks
a
week,
3
4
to
6
drinks
a
week,
4
7
to
13
drinks
a
week,
or
5
14
drinks
or
more
a
week?

3.
Since
your
last
interview
on
[
FILL
DATE],
how
many
times
did
you
drink
5
alcoholic
drinks
or
more
in
one
sitting?
Would
you
say 

1
Never,
2
1
time,
3
2
or
3
times,
4
4
or
5
times,
or
5
6
or
more
times?

{
END
OF
ALCOHOL
MODULE}
Partner
6
Month
(
Instrument
#
24)

12
Tobacco
(
update)

These
next
questions
are
about
your
use
of
tobacco
products.
This
includes
cigarettes,
chewing
tobacco,
snuff,
cigars,
and
pipe
tobacco.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
used
snuff,
dip,
or
chewing
tobacco,
even
once?

1
YES
2
NO
2.
Since
your
last
interview,
have
you
smoked
a
cigar
or
tobacco
pipe,
even
once?

1
YES
2
NO

SKIP
TO
Q3
2a.
How
often
have
you
smoked
cigars
or
tobacco
pipes
since
your
last
interview?

_____
NUMBER
OF
TIMES
ENTER
UNIT
1
DAY
2
WEEK
3
MONTH
[
IF
SMOKER
FROM
PREVIOUS
INTERVIEW,
ASK
Q3­
Q4
]
[
IF
NON­
SMOKER
IN
PREVIOUS
INTERVIEW,
SKIP
TO
Q5
]
3.
Do
you
still
smoke
cigarettes?

1
YES

SKIP
TO
Q6
2
NO
4.
When
did
you
stop
smoking?

MM/
YYYY

SKIP
TO
Q7
5.
In
your
last
interview
you
reported
that
you
were
not
smoking
cigarettes.
Are
you
currently
smoking
cigarettes
now?

1
YES
2
NO

SKIP
TO
Q7
6.
How
many
cigarettes
do
you
smoke
on
an
average
day
now?
Would
you
say 

1
Less
than
1
cigarette
per
day,
2
1
to
5
cigarettes,
3
6
to
10
cigarettes,
4
11
to
20
cigarettes,
5
21
to
40
cigarettes,
or
6
41
cigarettes
or
more?
Partner
6
Month
(
Instrument
#
24)

13
7.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
there
were
[
FILL
#]
cigarette
smokers
who
lived
in
your
home
not
including
yourself.
Is
this
still
correct?

1
YES

SKIP
TO
Q9
2
NO
8.
Not
including
yourself,
how
many
cigarette
smokers
live
in
your
home
now?

_____

9.
About
how
many
hours
per
day
are
you
in
the
same
room
with
someone
who
is
smoking
cigarettes,
cigars,
or
tobacco
pipes?

_____
Hours
999
Less
than
1
hour
a
day
{
END
OF
TOBACCO
MODULE}
Partner
6
Month
(
Instrument
#
24)

14
Acceptability
(
To
be
administered
at
the
end
of
the
home
visit)

This
study
will
be
able
to
answer
health
questions
best
if
we
are
able
to
keep
people
involved
in
the
study.
To
do
this,
we
would
like
to
get
some
feedback
from
you
about
the
study
overall
and
this
visit
today
to
help
improve
the
study
in
the
future.

1.
Was
participating
in
the
visit
today
convenient
for
you?

1
YES

SKIP
TO
Q6
2
NO
2.
Did
you
have
to
take
time
off
from
work
to
have
this
interview
today?

1
YES
2
NO
3.
Did
you
need
to
find
childcare
to
have
this
interview
today?

1
YES
2
NO
4.
Were
there
any
other
major
obstacles
for
you
to
have
this
interview
today?

1
YES
2
NO

SKIP
TO
Q6
5.
What
were
they?
(
ENTER
VERBATIM)

____________________________

6.
Is
there
anything
that
you
especially
like
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

7.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

8.
Finally,
do
you
have
any
recommendations
as
to
what
we
could
do
differently
in
the
overall
study
or
in
these
interviews?
(
ENTER
VERBATIM)

____________________________

{
END
OF
ACCEPTABILITY
MODULE}