No number Appendix E.15 PatOccup Hx

Appendix E15

Form Approved

OMB NO. __________

Exp. Date __________

Paternal Occupational Questionnaire

This questionnaire will ask about your work experience during the 3 months before your partner became pregnant until the birth of your child. We are interested in jobs that that were paid, volunteer, or military service, which lasted one month or more for 10 or more hours per week. Please do not include stay-at-home parenting and education activities as a job, we ask about those separately. Please circle your response or fill in blanks where indicated.

1. Between 3 months before the pregnancy and the date of your CHILD’s birth, did you have a job?

1 YES 2 NO 9 DON’T KNOW

2. During that time, were you enrolled as a regular (full-time) student?

(i.e. not just taking 1 class or community classes)

1 YES 2 NO-- SKIP TO 3 9 DON’T KNOW

2b. IF YES: At what level or grade were you enrolled? Please circle your response.

1 HIGH OR VOCATIONAL SCHOOL

2 COLLEGE—UNDERGRAD

3 GRAD OR PROFESSIONAL SCHOOL

9 Don’t Know

2c. IF COLLEGE OR ABOVE: What was your major field of study?

___________________________________________

2d. During which months before or during your partner’s pregnancy were you a regular student?(CIRCLE ALL THAT APPLY)

Before your partner’s pregnancy:

3 months before 2 months before 1 month before

During your partner’s pregnancy: (MONTHS)

1 2 3 4 5 6 7 8 9 10

DON’T KNOW

Public Reporting Burden Statement

Public reporting burden of 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

3. IF NOT A STUDENT OR NO JOB: Which of the following describes what you were doing during the 3 months before and during your partner’s pregnancy: (CIRCLE ALL THAT APPLY)

Stay at home parent or caregiver

Disabled

Unemployed/in between jobs

Incarcerated

Something else? SPECIFY:

Don’t know

3b. If you answered ‘unemployed’ to number 3, What was your usual job or job title?

______________________________________________

SKIP TO NEXT SECTION IF NO JOBS

4. We would like to know more about the jobs that you held between 3 months before the pregnancy and the birth of [CHILD] that lasted one month or more at 10 or more hours/week. We are interested in types of jobs, so if you worked different jobs with the same employer, include those as separate jobs. But if you were self-employed or a contractor doing similar work for different companies, include that as one job.

Please list each job by your title, the name of the companies or organizations you worked for (or whether self-employed), and the city it was located in, starting with the most recent during the pregnancy.

JOB TITLE EMPLOYER CITY/STATE

A. _________________________________________________________________________

B. _________________________________________________________________________

C. _________________________________________________________________________

D. _________________________________________________________________________

E. _________________________________________________________________________

F. _________________________________________________________________________

G. _________________________________________________________________________

Please answer questions 5-10 for each of the jobs you listed above (A-G). Additional sheets have been provided for each job title.

5. Job title (Fill in job titles specified under A-G):

6. When did you start working at this job? (MO/YR)

7. When did you stop working at this job? (MO/YR)

8. How many hours per week did you work on this job during the time period of interest?

(HRS/WK)

9. Please describe what type of business this was, or what the company made or did?

10. Please describe your main duties or activities for this job that is what you did and how you did it. Please be detailed.

__________________

11. At any of these jobs (or as a student), did you regularly, that is a least once per week, work with or around any substances or chemicals? Please include substances such as solvents or degreasers, pesticides, heavy metals, or radioactive materials (includes X-rays). If you answer No to this question, you have completed this questionnaire. Thank you. If you answer Yes, please answer the remaining questions.

1 YES 2 NO 8 REFUSED 9 DON’T KNOW

We would like to know more about the chemicals or substances that you may have used. Some of the names may not look familiar to you, but answer as best you can.

12, Did you work with or around any of the following at least once per week at any job you described (or school)?

If you answer ‘yes’ to any of the chemicals, please specify which months during the time period you were around this chemical. check all months in which exposure occurred OR MARK DON’T KNOW.

1

2

8

9

Months before and during pregnancy

YES

NO

RF

DK

-3

-2

-1

1

2

3

4

5

6

7

8

9

10

Oil-based paints

Lacquers

Varnishes

Paint thinners

Paint strippers

Automotive fluids (SPECIFY BELOW)

Freon

Antifreeze

Gasoline

Degreasers

Brake fluid

Toluene, xylene, styrene or benzene

Carbon disulfide

Carbon tetrachloride

Perchlorethylene (perc)

Trichloroethylene (TCE) or trichlorethane (TCA)

Vinyl chloride

Glycol ethers

Alcohols, such as methanol or ethanol

Adhesives or glues, like rubber cement

Any other solvents or degreasers? (SPECIFY)

Phthalates

Cutting oils

Cooling or lubricating oils

PCBs

Metals (PROBE & SPECIFY)

Lead

Nickel

Chromium

Mercury

Manganese

Metal dust or fumes

Others?

Anesthetic gases

Ethylene oxide

Pesticides or herbicides, e.g. bug or weed killers (SPECIFY & NAME BELOW IF KNOWN)

Herbicides

Fungicides

Insecticides

Rat poison

X-ray or radioactive materials

Diesel fumes

Pharmaceuticals or drugs SPECIFY:

Any other? (please specify)

12b. Please describe the activities you were doing around these substances you mentioned (at which job), including how often you were around them.

______________________________________________________________________________

12c. Did you work mostly indoors, outdoors, or both?

1 INDOORS 2 OUTDOORS 3 BOTH 9 DON’T KNOW

12d.When you were around these, did you usually use any protective gear or equipment such as gloves, masks, respirators or fume hoods?

1 YES 2 NO

12e. IF YES: Which did you use? (CIRCLE ALL THAT APPLY)

GLOVES OR PROTECTIVE CLOTHING

GOGGLES

MASK

RESPIRATOR

FUME HOOD OR LOCAL VENTILATION

OTHER (Specify):______________________

DON’T KNOW