Document ID: EPA-HQ-ORD-2005-0010-0037
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

NCS
Herald
Cohort
Study
Instrument
#
29
Female
New
Home
Location
Questionnaire
Update
for
any
new
addresses
Eligibility:
Any
woman
who
moved
to
a
new
address
Mode
of
administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
5
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.
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

PRELOADED
DATA:

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

Respondent
Name
Respondent
Address
and
Phone
QUESTIONNAIRE:
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

Home
Environment/
Conditions
(
Full)

The
next
series
of
questions
are
related
to
your
home
environment,
including
your
water
sources,
heating,
and
air
conditioning.

1.
How
long
have
you
lived
at
this
address:
{
FILL
PRELOAD
ADDRESS}?

______
YEARS
_______
MONTHS
2.
Which
water
source
is
used
more
than
half
the
time
for
cooking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

3.
Which
water
source
is
used
more
than
half
the
time
for
drinking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

4.
Do
you
use
any
of
the
following
to
treat
your
water
at
home?
(
CODE
ALL
THAT
APPLY)

1
A
water
softener?
2
Charcoal
filters?
3
Reverse
osmosis?
4
Distillation?
5
Something
else?
(
SPECIFY)_______________________

Heat
and
Air
Conditioning
1.
Which
fuels
are
used
for
heating
this
residence?
(
CODE
ALL
THAT
APPLY)

1
Gas:
from
underground
pipes
serving
the
neighborhood
2
Gas:
bottled,
tank,
or
LP
3
Electricity
4
Fuel
oil,
kerosene,
etc
5
Coal
or
coke
6
Wood
7
Solar
energy
8
Propane
9
Other
fuel
(
SPECIFY)
____________________

2.
Does
this
residence
have
a
central
heating
system
with
ducts
that
blow
air
into
most
rooms?

1
YES
2
NO
3.
During
which
month
do
you
usually
start
using
heating
devices?
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

_____

4.
During
which
month
do
you
usually
stop
using
heating
devices?

_____

5.
During
the
months
that
you
use
heating
devices,
do
you
use
portable
kerosene
heaters
in
this
residence?

1
YES
2
NO

SKIP
TO
Q7
6.
How
often
do
you
use
your
kerosene
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
7.
During
the
heating
season,
is
a
portable
or
nonvented
gas
(
non­
kerosene)
heater
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q9
8.
How
often
do
you
use
a
portable
or
nonvented
gas
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
9.
During
the
heating
season,
is
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q11
10.
How
often
do
you
use
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
11.
Is
air
conditioning
(
refrigeration)
used
to
cool
this
residence?
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

1
YES
2
NO

SKIP
TO
NEXT
SECTION
12.
Which
of
the
following
types
of
air
conditioning
units
do
you
use?
(
CODE
ALL
THAT
APPLY)

1
Central
unit/
units?
2
Window
or
wall
unit/
units?
3
Portable
unit/
units?

13.
During
which
month
do
you
usually
start
using
air
conditioning
to
cool
this
residence?

_____

14.
During
which
month
do
you
usually
stop
using
air
conditioning?

_____

Cooking
1.
Do
you
use
a
gas
stove
for
cooking?

1
YES
2
NO
2.
Do
you
use
a
gas
stove
for
any
other
purpose
than
cooking,
for
example,
drying
clothes
or
heating
a
room?

1
YES
2
NO
Pesticides
and
Lawn
Care
Now
I'm
going
to
ask
you
about
the
use
of
pesticides
and
lawn
treatments
in
and
around
your
home.

1.
In
the
past
6
months,
were
any
chemicals
used
inside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q6
2.
In
the
past
6
months,
what
rooms
in
your
home
were
treated
with
products
for
the
control
of
termites,
insects,
rodents,
or
other
pests?
(
CODE
ALL
THAT
APPLY)

1
Living
room
2
Family
room
3
Dining
room
4
Kitchen
5
Bathroom(
s)
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

6
Bedroom(
s)
7
Other
rooms
3.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
inside
this
residence?
_______

b.
did
you
apply
these
products
inside
this
residence?
_______

4.
In
what
month
were
they
last
used
inside
this
residence?

_____

5.
What
were
the
names
of
the
products
last
used
inside
this
residence?

_________________
_________________
_________________

6.
In
the
past
6
months,
were
any
chemicals
used
outside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q10
7.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
outside
this
residence?
_______

b.
did
you
apply
these
products
outside
this
residence?
_______

8.
In
what
month
were
they
last
used
outside
this
residence?

_____

9.
What
were
the
names
of
the
products
last
used
outside
this
residence?

_________________
_________________
_________________

10.
In
the
past
6
months,
have
you
had
any
regular
lawn
or
yard
treatments?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
11.
Who
usually
applies
these
treatments?
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

1
You,
2
A
professional,
or
3
Someone
else?
The
next
few
questions
are
about
the
general
condition
of
your
home.

Renovations
and
Paint
1.
In
the
last
6
months,
which
of
the
following
have
been
performed
in
this
home?
(
CODE
ALL
THAT
APPLY)

1
Adding
a
room?
2
Putting
up
or
taking
down
a
wall?
3
Replacing
windows?
4
Refinishing
floors?
5
Exterior
painting?
6
Interior
painting
2.
Over
the
last
6
months,
how
would
you
rate
the
typical
condition
of
the
painted
surfaces
 
the
walls,
trim,
etc.
 
inside
this
residence?
Would
you
say 

1
Excellent,
2
Very
good,
3
Fair,
or
4
Poor?

Water
Damage
/
Mold
1.
Water
damage
includes
water
stains
on
the
ceiling
or
walls,
rotting
wood,
and
flaking
sheetrock
or
plaster.
This
damage
may
be
from
broken
pipes,
a
leaky
roof
or
floods.
Have
you
seen
any
water
damage
in
your
home?

1
YES
2
NO
2.
Have
you
seen
any
mold
or
mildew
on
walls
or
other
surfaces
other
than
food,
inside
your
home?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
3.
In
which
rooms
have
you
seen
the
mold
or
mildew?
(
CODE
ALL
THAT
APPLY)

1
Kitchen
2
Living
room
3
Hall/
landing
4
Your
bedroom
5
Other
bedrooms
6
Bathroom/
toilet
{
END
OF
HOME
ENVIRONMENT
MODULE}
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

Neighborhood
(
Full)

Now
I'd
like
to
ask
you
about
the
neighborhood
you
live
in.

1.
In
your
opinion,
is
your
neighborhood 

1
A
very
good
place
to
live
2
A
fairly
good
place
to
live
3
Not
a
very
good
place
to
live,
or
4
Not
at
all
a
good
place
to
live?

2.
How
often
do
people
in
your
neighborhood 

Never
Rarely
Sometimes
Often
Always
DK
a.
Visit
your
home?
0
1
2
3
4
­
1
b.
Argue
with
you?
0
1
2
3
4
­
1
c.
Look
after
your
children?
0
1
2
3
4
­
1
d.
Keep
to
themselves?
0
1
2
3
4
­
1
e.
Attend
religious
services?
0
1
2
3
4
­
1
3.
Is
your
neighborhood 

Not
at
all
Sometimes
Usually
a.
Lively?
0
1
2
b.
Polluted/
dirty?
0
1
2
c.
Friendly?
0
1
2
d.
Noisy?
0
1
2
e.
Clean?
0
1
2
f.
Attractive?
0
1
2
4.
Have
you
ever
asked
a
neighbor 
(
CODE
ALL
THAT
APPLY)

1
To
help
with
minor
household
tasks
or
repairs?
2
To
give
you
a
ride
somewhere?
3
To
help
take
care
of
you
or
a
family
member
when
you
are
sick?
4
To
borrow
money?
5
To
borrow
other
items
such
as
food
or
tools?

5.
Do
you
feel
that
your
neighborhood
is 

1
Very
safe
2
Somewhat
safe
3
Somewhat
unsafe,
or
4
Very
unsafe?

6.
In
your
opinion,
does
your
neighborhood
have
problems
with 
(
CODE
ALL
THAT
APPLY)

1
Property
crimes
such
as
break­
ins
or
burglaries?
2
Personal
crimes
such
as
muggings
or
beatings?
3
Violent
crimes?
4
Drug
dealing?
Female
New
Home
Location
Questionnaire
 
update
to
new
address
(
Instrument
#
29)

7.
From
where
you
live,
is
it
relatively
easy
for
you
to
get
to 
(
CODE
ALL
THAT
APPLY)

1
stores
to
get
the
groceries
you
need?
2
public
parks
or
recreational
facilities?
3
doctor's
offices
or
clinics?
4
your
religious
institution?
5
your
children's
schools?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]
6
daycare
programs?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]

8.
Are
you
a
member
of
any
religious
faith?

1
YES
2
NO

SKIP
TO
END
9.
How
often
do
you
go
to
a
place
of
worship?

1
At
least
once
a
week
2
At
least
once
a
month
3
At
least
once
a
year
4
Or
not
at
all?

{
END
OF
NEIGHBORHOOD
MODULE}