CURHAN Base Protocol Environmental Exposure

ENVIRONMENTAL EXPOSURE QUESTIONNAIRE

 

Housing Characteristics

  1. How would you describe your current residence?
  • Apartment or condo with more than 10 floors
  • Apartment or condo with 5-10 floors
  • Apartment or condo with 1-4 floors
  • Nursing home
  • Dormitory
  •      House?
  • Other (Please specify: _________________________)

 

  1. In what decade was this residence built (If unknown, enter N/A)?

Enter Year:

  1. How many rooms are in this residence? Count the kitchen but not the bathroom. Do not count bathrooms, laundry rooms, or unfinished basements.

 

Enter a number between 1 and 25: _____________________

 

  1. Is this residence owned, being bought, rented, or occupied by some other arrangement by you or someone else in your family?

 

Owned or being bought

Rented

Other arrangement (Please specify: ______________________)

 

Heating

  1. What is the main source of heat at this residence?
  • Gas
  • Electricity
  • Fuel oil
  • Kerosene
  • Propane
  •      Coal
  • Wood
  • Solar
  •      Other (Please specify: _________________________)
  1. During which months do you usually use the heat?

 

________(month) to _________(month)

 

Cooking

  1. What is the energy source for the cooking stove top or range top at this residence?

 

  • Gas
  • Electricity
  • Fuel oil
  • Kerosene
  • Propane
  •      Coal
  • Wood
  • Solar
  •      I do not have one
  •      Other (Please specify: _________________________)

<If answer is i, skip to Question 13>

  1. How often do you use the cooking stove top at this residence?
  • < 1x Week
  • Weekly
  • Daily

 

  1. How many times do you use the cooking stove top per above (week or day)?
  2. What is the main cooking oil you use?
  • Vegetable oil
  • Animal fat

11.What is your most common cooking method

  • Boil
  • Stir fry
  • Deep fry
  • Steam

12.Do you use the overhead vent fan when you cook?

  • I do not have one
  • Rarely
  • Sometimes
  • Often
  • Always

Home Ventilation

13.How often do you open windows in each season?

Spring:            Never    <1 day/month       1-3day/month      1 day/week         daily

Summer:         Never    <1 day/month       1-3day/month      1 day/week         daily

Fall:          Never    <1 day/month       1-3day/month      1 day/week         daily

Winter:            Never    <1 day/month       1-3day/month      1 day/week         daily

14.Does your residence have central air conditioning?

  • Yes
  • No

<If no, skip to Question 16>

15. How often do you usually use the central air conditioning during:

Spring:             All day    6-12 hours/day 1-6 hours/day
Summer:   All day    6-12 hours/day       1-6 hours/day

 

Fall:           All day      6-12 hours/day 1-6 hours/day

 

Winter:             All day    6-12 hours/day       1-6 hours/day
16.Do you have an air conditioning unit in your residence?

  • Yes
  • No

<If no, skip to Question 18>

17.How often do you usually use the air conditioning unit during:

 

Spring:             All day    6-12 hours/day 1-6 hours/day
Summer:   All day    6-12 hours/day       1-6 hours/day

 

Fall:           All day      6-12 hours/day 1-6 hours/day

 

Winter:             All day    6-12 hours/day       1-6 hours/day

 

18.Do you have an air purifier/HEPA filter in your residence?

 

  • Yes
  • No 

<If no, skip to Question 20>

 

19.How often do you use the air purifier?

  • Daily
  • Weekly
  • <1x/week

20.Do you have an air humidifier?

 

  • Yes
  • No

<If no, skip to Question 22>

21.How often do you use the air humidifier?

 

  • Daily
  • Weekly
  • <1x/week

Drinking Water

 

22.What is the main source of drinking water at this residence?

 

  • Bottled (large water cooler or small bottles)
  • Boiled tap water
  • Filtered tap water
  • Others (Please specify: _________________________)

23.Was there ever a change in the main source of drinking water at this residence?

 

  • Yes
  • No

<If no, skip to Question 25>

24.What was the reason for the change?

 

______________________________________________________________

 

25.What is the main source of water for making tea, coffee and other drinks?

 

  • Bottled (large water cooler or small bottles)
  • Tap
  • Others (Please specify: _________________________)

 

Condition Around Residence

27.How would you describe the noise at your residence during rush hour?

 

  • Very quiet
  • Quiet
  • Moderate
  • Loud
  • Very loud

 

28.How would you describe the noise at your residence at night (10:00 pm – 6:00 am)?

 

  • Very quiet
  • Quiet
  • Moderate
  • Loud
  • Very loud

 

29.Do you have any green space within your building complex/residence?

 

  • Yes
  • No

<If no, skip to Question 32>

30. How close is the nearest green space to your home (outside of your complex/home)?

 

______________________________________________________________

 

Do you use this green space for recreational activity?

  1. Yes
  2. No

<If no, skip to Question 32>

 

 

31.How often do you use nearby (outside of building complex/residence) green space for recreational activity?

 

  • Never
  • Sometimes
  • Often
  • In the past but no more

 

32. Is your residence within 1 km of:

 

  • A power plant? If so, what kind of power plant?
  • Bus station (depot)
  • Gas station
  • A factory (Please specify type: _________________________)
  • Airport
  •      Farm

Smoking:

Now I would like to ask you a few questions about smoking in this home.

33. How many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product?

 

Enter number: _____________

 

34. Not counting decks, porches, or detached garages, how many people who live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, or any other tobacco product inside this home?

 

Enter number: _____________

 

 

35. Not counting decks, porches, or detached garages) During the past 7 days, that is since last [TODAY’S DAY OF WEEK], on how many days did {anyone who lives here/you}, smoke tobacco inside this home?

 

Enter number {between 0 and 7 days}: _______________

 

36. Have you ever smoked a cigarette in your lifetime?

  • Yes
  • No

<If no, skip to Question 51>

37. Have you smoked at least 100 cigarettes in your entire life?

 

  • Yes
  • No

<If you have never married or cohabited, skip to Question 39>

38. Did your spouse/partner smoke at least 100 cigarettes in his/her entire life?

  • Yes
  • No

 

39. How old were you when you first started to smoke cigarettes regularly?

 

  • Enter Age: ______________
  • I don’t smoke regularly

 

40. Do you now smoke cigarettes . . .

 

  • Everyday
  • Some days
  • I don’t smoke anymore

<If answer is C, skip to Question 51>

Smoking History

41. During the past 30 days, on how many days did you smoke cigarettes?

 

Enter number (in days): ___________________

 

42. During the past 30 days, on the days that you smoked, how many cigarettes did you smoke per day?

 

Enter number (in days): _____________________

 

43. What brand of cigarettes do you usually smoke?

 

Enter brand: _____________________

 

44. May I please see the pack for the brand of cigarettes you usually smoke, if carton is unavailable please include brand and cigarette type?

 

Enter 8 or 12 digit UPC code:

 

45. Is the cigarette unfiltered or filtered?

 

  • Filtered
  • Unfiltered
  • Unknown

 

46. What is the cigarette product size?

 

  • Regular
  • Kings
  • 100s
  • 120s
  • Unknown

 

47. Are there other names that these cigarettes are referred to as?

 

  • Smooth
  • Deluxe
  • Hardpack
  • Lights
  • Milds
  •      Slims
  • Specials
  • Super
  •      Ultra lights
  •      Others (Please specify: _________________________)
  • Unknown

 

48. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

Yes

No

49. What was the reason for you to try to quit?

 

___________________________________________________________

During the past 12 months, how many times have you stopped smoking cigarettes because you were trying to quit smoking?

 

Enter number (in days): __________________________________

 

50. The last time you tried to quit, how long were you able to stop smoking?

 

Enter number of days, weeks and months: ________________________

<Proceed to Question 56>

Smoking Cessation

 

51. How long has it been since you quit smoking cigarettes (please answer to the best of your ability)?

 

Enter years/months/days: ____________________

 

52. How old were you when you last smoked cigarettes regularly (please answer to the best of your ability)?

 

Enter age (years): ____________________

 

 

53. At that time, about how many cigarettes did you usually smoke per day (please answer to the best of your ability)?

 

Enter number (pear day): ____________________

 

 

54. On average, how many days in a month did you smoke cigarettes when you were smoking (please answer to the best of your ability)?

 

Enter number (in days): ___________________

 

 

55. On average, on the days that you smoked, how many cigarettes did you smoke per day (please answer to the best of your ability)?

 

Enter number (in days): _____________________

 

Smoking in Your Environment

56. During the last 7 days, were you working at a job or business outside of the home where someone else smoked cigarettes or other tobacco products indoors?

 

  • Yes
  • No
  • Unknown

57. During the last 7 days, did you spend time in a restaurant in which someone else smoked cigarettes or other tobacco products indoors?

 

  • Yes
  • No
  • Unknown

 

 

58. During the last 7 days, did you spend time in a bar in which someone else smoked cigarettes or other tobacco products indoors?

 

  • Yes
  • No
  • Unknown

 

59. During the last 7 days, did you ride in a car or motor vehicle in which someone else smoked cigarettes or other tobacco products?

 

  • Yes
  • No
  • Unknown

 

 

60. During the last 7 days, did you spend time in a home other than your own in which some else smoked a cigarette or other tobacco product indoors?

 

  • Yes
  • No
  • Unknown

 

61. During the last 7 days, did you spend time in any other indoor area, not including a job/business, restaurant, bar, a car, or someone else’s home, in which someone else smoked a cigarette or other tobacco product?

 

  • Yes
  • No
  • Unknown

Time Activity Patterns

62. How much time do you typically spend outdoors during the week?

 

Enter number (in hours): ___________________

 

 

63. How much time do you typically spend outdoors during the weekend?

 

Enter number (in hours): ____________________

 

 

64. How much time do you typically spend commuting?

 

Enter number (in hours): _____________________

 

 

65. What routes of transportation do you typically use for commuting? Indicate all that apply

 

WALK            0-30 min     30min -1 hr        1-2hr            2+hr

 

BICYCLE    0-30 min     30min -1 hr        1-2hr            2+hr

 

BUS             0-30 min     30min -1 hr        1-2hr            2+hr

 

SUBWAY   0-30 min     30min -1 hr        1-2hr            2+hr

 

CAR            0-30 min     30min -1 hr        1-2hr            2+hr

 

 

66. Do you exercise outdoors?

 

Enter number (in hours): ________________________

 

Chemical Exposure

 

67. Do you believe that you have been exposed to any of the following chemicals at work, at home, through hobbies, or in some other manner?

 

  • Yes
  • No

 

<If no, skip to question 71>

 

68. If yes circle all that apply:

  • Perchloroethylene (dry cleaning fluid)
  • Dioxins, Agent Orange
  • Carbon Monoxide
  • Mercury
  • Lead
  •      Manganese
  • Nail polish, polish removers (acetone)
  • TCE, degreasers
  •      PBDEs (flame retardants)
  •      Waste anesthetic gases
  • Arsenic
  •      Cadmium
  • Aluminum
  • Pesticide
  • Mold
  • Fuel Oil
  • Gasoline
  •      Chloroform
  • Acrylamide
  •      Other (Please specify type: _________________________)

 

69. When were you exposed to such chemicals?

 

________ Year __________ Month

 

70. Why were you exposed to such chemicals?

 

__________________________________________________________

 

Insect Repellant Exposure

 

71. In the past 12 months, have you used any chemical insect repellant on your skin, hair, or clothing?

  • Yes
  • No

 

<If no, end of questionnaire>

72. Over the past 12 months, how often did you use repellants during the summer?

  • All of the time
  • Most of the time
  • Half of the time
  • Some of the time
  • Rarely
  • Never

73. Over the past 12 months, how often did you use repellants during the rest of the year?

  • All of the time
  • Most of the time
  • Half of the time
  • Some of the time
  • Rarely
  • Never

<End of questionnaire>


CURHAN Environmental Exposure Protocol, March 9, 2016

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About 陈馨雨

2014级本科生
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