ID Number
Attachment 4 Pre- and Post-Shift Red Tide Questionnaire
Form Approved
OMB no. 0920-0494
Exp. Date xx/xx/20xx
DAY 1: Pre-Shift
1. INTERVIEWER NAME ___________________
2. DATE OF INTERVIEW ____/____/____
mm dd yyyy
3. TIME ___:___ am / pm
4. LOCATION ______________________________
STREET ADDRESS
______________________________
NAME OF BEACH
______________________________
CITY
______________________________
STATE, ZIP
______________________________________________________________________________
Home Phone: (_________) _________ ‑ _________________
Public reporting burden for
this collection of information is estimated to vary from 15 to 25
minutes per response, with an average response of 20 minutes,
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; Paperwork Reduction Project (0920-0494);
M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333
To begin this part of the interview, I have a few questions about your home and your job.
5. Does your home have air conditioning?
1. NO (GO TO QUESTION 6)
2. YES (GO TO QUESTION 5a)
88. DON’T KNOW
99. REFUSED
5a. Are you using it regularly? 1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
5b. Did you use your air conditioner last night?
1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
6. What is your job title? 1. LIFEGUARD
2. MARINE BIOLOGIST/
RESEARCH ASSISTANT
3. OTHER
Specify __________________________
88. DON’T KNOW
99. REFUSED
7. Counting the time you are at work and other times, about how many hours do you spend on the water during the average work week?
1. __________ hours
88. DON’T KNOW
99. REFUSED
8. When was the last time you were on the water while at work before today.
1. YESTERDAY
2. WITHIN THE LAST WEEK
3. WITHIN THE LAST MONTH
4. OTHER
Specify __________________________
88. DON’T KNOW
99. REFUSED
9. About how many hours do you spend on the beach or close to shore during the average work week? 1. __________ hours
88. DON’T KNOW
99. REFUSED
10. When was the last time you were on the beach or close to shore while at work before today?
1. YESTERDAY
2. WITHIN THE LAST WEEK
3. WITHIN THE LAST MONTH
4. OTHER
Specify __________________________ 88. DON’T KNOW
99. REFUSED
11. Have you ever been on the water or on the beach or shore during a red tide?
1. NO (GO TO QUESTION 12)
2. YES (GO TO QUESTION 11a)
88. DON’T KNOW
99. REFUSED
11a. Did you have any symptoms or health problems during the red tide?
1. NO (GO TO QUESTION 12)
2. YES (GO TO QUESTION 11a1)
77. NA
88. DON’T KNOW
99. REFUSED
Can you tell me what your symptoms were and whether you felt they were mild, moderate, or severe?
11a1. Cough 1. NO 11a1a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a2. Wheezing 1. NO 11a2a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a3. Throat irritation
1. NO 11a3a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a4. Shortness of breath
1. NO 11a4a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a5. Chest heaviness or tightness
1. NO 11a5a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a6. Nasal congestion
1. NO 11a6a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a7. Eye irritation/tearing
1. NO 11a7a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a8. Headache 1. NO 11a8a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a9. Itchy skin 1. NO 11a9a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a10. Diarrhea 1. NO 11a10a.1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
11a11. Other 1. NO 11a11a.1. MILD
2. YES 2. MODERATE
Specify 3. SEVERE
____________ 77. NA
77. NA 88. DON’T KNOW
88. DON’T KNOW 99. REFUSED
99. REFUSED
Now, I am going to ask you about a series of symptoms, and I’d like you to tell me if you are having the symptom now, and whether it is mild, moderate, or severe.
12a1. Cough 1. NO 12a1a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a2. Wheezing 1. NO 12a2a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a3. Throat irritation
1. NO 12a3a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a4. Shortness of breath
1. NO 12a4a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a5. Chest heaviness or tightness
1. NO 12a5a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a6. Nasal congestion
1. NO 12a6a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a7. Eye irritation/tearing
1. NO 12a7a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a8. Headache 1. NO 12a8a. 1. MILD
2. YES 2. MODERATE
3. YES-UNRELATED 3. SEVERE
77. NA 77. NA
88. DON’T KNOW 88. DON’T KNOW
99. REFUSED 99. REFUSED
12a9. Itchy skin 1. NO 12a9a. 1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a10. Diarrhea 1. NO 12a10a.1. MILD
2. YES 2. MODERATE
77. NA 3. SEVERE
88. DON’T KNOW 77. NA
99. REFUSED 88. DON’T KNOW
99. REFUSED
12a11. Other 1. NO 12a11a.1. MILD
2. YES 2. MODERATE
Specify 3. SEVERE
______________ 77. NA
77. NA 88. DON’T KNOW
88. DON’T KNOW 99. REFUSED
99. REFUSED
Now, I need to ask you a few questions that will help us interpret the results of your pulmonary function tests.
13. Have you taken any medications, including allergy or asthma medicines, such as inhalers, antihistamines, or cough medicine today?
1. NO
2. YES
88. DON’T KNOW
99. REFUSED
14. Have you had a cold in the last three weeks? 1. NO
2. YES
88. DON’T KNOW
99. REFUSED
15. Have you smoked a cigarette in the last hour? 1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
Now, just a few more questions about your height and weight:
16. Have you lost or gained 10 or more pounds in the last month?
1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
17. Height _________ inches
18. Weight _________ pounds
That is my last question for this part of the interview. Now, we would like to have you do some pulmonary function tests.
Form Approved
OMB no. 0920-0494
Exp. Date xx/xx/20xx
DAY 1: Post-Shift Red Tide Questionnaire
1. INTERVIEWER NAME ___________________
2. DATE OF INTERVIEW ____/____/____
mm dd yyyy
3. TIME ___:___ am / pm
4. LOCATION ______________________________
STREET ADDRESS
______________________________
NAME OF BEACH
______________________________
CITY
______________________________
STATE, ZIP
______________________________________________________________________________
5. At what time did you start your shift today? ____:_____ am / pm
6. Since we talked this morning, about how many hours have you spend on the water?
___________ HOURS
88. DON’T KNOW
99. REFUSED
7. Since we talked this morning, about how many hours did you spend on the beach or near the shore? ___________ HOURS
88. DON’T KNOW
99. REFUSED
I am going to read a list of symptoms to you. Would you please tell me if you had that symptom during your work day today, about when the symptom started, and about how long it lasted?
I also want to know if you thought the symptom was mild, moderate, or severe.
NOTE TO INTERVIEWERS:
IF STUDY PARTICIPANT REPORTS THAT THEY EXPERIENCED A SYMPTOM, IT WENT AWAY, AND THEN RECURRED, PLEASE RECORD THE TIME AND SEVERITY INFORMATION FOR THE FIRST OCCURRENCE ANSWER YES TO QUESTION 8l.
8a. Cough 1. NO
2. YES
8a1. WHEN STARTED ___:___ am / pm
77. NA
8a2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8a3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8b. Wheezing 1. NO
2. YES
8b1. WHEN STARTED ___:___ am / pm
77. NA
8b2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8b3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8c. Throat irritation 1. NO
2. YES
8c1. WHEN STARTED ___:___ am / pm
77. NA
8c2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8c3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8d. Shortness of breath 1. NO
2. YES
8d1. WHEN STARTED ___:___ am / pm
77. NA
8d2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8d3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8e. Chest heaviness or tightness 1. NO
2. YES
8e1. WHEN STARTED ___:___ am / pm
77. NA
8e2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8e3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8f. Nasal congestion 1. NO
2. YES
8f1. WHEN STARTED ___:___ am / pm
77. NA
8f2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8f3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8g. Eye irritation/tearing 1. NO
2. YES
8g1. WHEN STARTED ___:___ am / pm
77. NA
8g2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8g3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8h. Headache 1. NO
2. YES
8h1. WHEN STARTED ___:___ am / pm
77. NA
8h2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8h3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8i. Itchy skin 1. NO
2. YES
8i1. WHEN STARTED ___:___ am / pm
77. NA
8i2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8i3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8j. Diarrhea 1. NO
2. YES
8j1. WHEN STARTED ___:___ am / pm
77. NA
8j2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8j3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8k. Other 1. NO
2. YES
8k4. Specify ______________________
8k1. WHEN STARTED ___:___ am / pm
77. NA
8k2. HOW LONG DID SYMPT. LAST?
__________ HOURS
66. ONGOING
77. NA
77. NA
88. DON’T KNOW
99. REFUSED
8k3. 1. MILD
2. MODERATE
3. SEVERE
77. NA
88. DON’T KNOW
99. REFUSED
8l. SYMPTOMS RECURRED DURING THE SHIFT
1. YES
2. NA
88. DON’T KNOW
99. REFUSED
IF NO TO QUESTION 8, SKIP TO QUESTION 13
9. Did your symptoms make you to stop working or performing your usual activities?
1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
10. Did your symptoms make you leave the area of the beach or shore?
1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
11. Did your symptoms get better when you left the area of the water OR (beach or shore)?
1. NO (GO TO QUESTION 12)
2. YES (GO TO QUESTION 11a)
77. NA
88. DON’T KNOW
99. REFUSED
11a. About how long did it take after leaving the area for your symptoms to get better?
__________ hours
66. ONGOING
77. NA
88. DON’T KNOW
99. REFUSED
12. Do you still have these symptoms?
1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
13. Did anyone you were with experience any of these symptoms today?
1. NO
2. YES
88. DON’T KNOW
99. REFUSED
Now, I need to ask you a few questions that will help us interpret the results of your pulmonary function tests.
14. Have you taken any medications, including allergy or asthma medicines, such as inhalers,
antihistamines, or cough medicine today?
1. NO
2. YES
88. DON’T KNOW
99. REFUSED
15. Have you had a cold in the last three weeks? 1. NO
2. YES
88. DON’T KNOW
99. REFUSED
16. Have you smoked a cigarette in the last hour? 1. NO
2. YES
77. NA
88. DON’T KNOW
99. REFUSED
That is the end of this part of the interview. Thanks very much for your help with this study.
| File Type | text/rtf |
| File Title | Microsoft Word - 6827_09-02-05 Red Tide Final SS |
| Author | __aaes__ |
| Last Modified By | tfs4 |
| File Modified | 2009-02-06 |
| File Created | 2009-02-06 |