Resident Post-Intervention Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Smoke-Free

Multi-Unit Housing Policy Study:

Resident Survey – Post-Intervention

English Version

Los Angeles County Department of Public Health

Tobacco Control & Prevention Program

Healthy Housing Solutions, Inc.

Westat

CDC

NOTE: POST-INTERVENTION SURVEY IS THE SAME AS BASELINE SURVEY FOR CURRENT REVIEW PURPOSES. POST-INTERVENTION SURVEY WILL REDUCE THE NUMBER OF QUESTIONS AND MODIFY RESPONSE CATEGORIES BASED ON THE RESULTS OF THE BASELINE.

Public reporting burden of this collection of information is estimated to average 45-60 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)

Table of Contents

Section A: Housing Characteristics and Environment

Questions A1-A18 4

Section B: Secondhand Smoke Exposure

Questions B1-B17 8

Section C: Knowledge, Attitudes & Beliefs about Secondhand Smoke,

Housing Policy Implementation & Enforcement Issues

Questions C1-C23 14

Section D: Smoking Status and Cessation Behaviors among Residents

Questions D1-D19 22

Section E: Smoking-Related Illnesses

Questions E1-E30 27

Section F: Respondent Characteristics

Questions F1-F10 33

Section G: Children’s Module

Questions G1-G32 35

Visual Assessment 52

The Los Angeles County Department of Public Health, Healthy Housing Solutions, Inc., and Westat acknowledge that this survey adapts questions from many sources, most especially:

• Roswell Park Cancer Institute’s surveys of Multi-Unit Housing Operators and Residents;

• Multi-unit Housing Owner/Manager Survey Questionnaire funded by the California Department of Public Health’s Tobacco Control Program and conducted on behalf of the University of California, Los Angeles and the California Apartment Association;

• Behavioral Risk Factor Surveillance Survey 2011;

• Los Angeles County Health Survey 2011;

• Massachusetts Tobacco Survey – Adults;

• California Tobaccos Survey – Adults;

• Strata Corporation and Context Research, Ltd. Residents in MultiUnit Dwellings, 2008. Conducted on behalf of the Heart and Stroke Foundation of B.C. and Yukon to support the British Columbia Smoke-Free Housing in Multi-Unit Dwelling (MUDs) Initiative; and

• National Survey of Lead and Allergens in Housing: Resident Questionnaire sponsored by the U.S. Department of Housing and Urban Development and the National Institute of Environmental Health and Sciences.

SECTION A: HOUSING CHARACTERISTICS & ENVIRONMENT

I’d like to start with getting some background on your apartment and the neighborhood.

A1. How long have you lived in your current apartment unit? ?

NUMBER OF YEARS |___|___|  IF LESS THAN 1 YEAR,

ENTER “0”

NUMBER OF MONTHS |___|___|  IF LESS THAN 1 MONTH,

ENTER “1”

REFUSED -7

DON’T KNOW -8

A2. On a scale of 1 to 10, how would you rate this apartment complex as a place to live? 10 is best, 1 is worst.

10	9	8	7	6	5	4	3	2	1
BEST									WORST

REFUSED -7

DON’T KNOW -8

A3. Would you agree or disagree with the next two statements?

	AGREE	SOME DO/ SOME DON’T	DISAGREE	RE	DK
A3a. The people in this apartment complex know each other well	1	2	3	-7	-8
A3b. The people in this apartment complex care about each other	1	2	3	-7	-8

A4. I am going to read you a list of different ways to heat or cool your apartment. In the past 6 months, how often have you used each of the following items to heat or cool your apartment?

	[In the past 6 months, would you say you used it . . .
HEATING, AIR AND VENTILATION	Daily,	Weekly,	Monthly,	Never,	Don’t have, or	Does not work?]	RE	DK
a) Central air and/or heating?	1	2	3	4	5	6	-7	-8
b) Space heaters and/or wall heaters?	1	2	3	4	5	6	-7	-8
c) Stand alone fans and/or ceiling fans?	1	2	3	4	5	6	-7	-8
d) Window unit and/or stand alone air conditioners?	1	2	3	4	5	6	-7	-8

Now I am going to ask some questions about other conditions in your apartment in the past 6 months.

A5. In the past 6 months, has there been water or dampness in your home due to broken pipes, leaks, heavy rain or other reasons?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

A6. In the past 6 months, have you had any problems with cockroaches?

YES 1

N O 2

REFUSED -7 GO TO A8

DON’T KNOW -8

A7. When was the last time you saw cockroaches inside your home? Was it…

Within the last week, 1

Within the last month, 2

2-4 months ago, or 3

4-6 months ago? 4

REFUSED -7

DON’T KNOW -8

A8. In the past 6 months, have you had any problems with mice or rats?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

A9. In the past 6 months, have you had any pet with fur living in your home?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

A10. In the past 7 days, on how many days was the apartment vacuumed?

NUMBER OF DAYS |___|___|

NOT APPLICABLE (no vacuum) 1

REFUSED -7

DON’T KNOW -8

A11. In the past 7 days, on how many days were the floors swept?

NUMBER OF DAYS |___|___|

NOT APPLICABLE (no broom) 1

REFUSED -7

DON’T KNOW -8

Now I am going to ask about sources of smoke that can be found in apartments.

A12. What kind of cooking stove do you have?

GAS 1

ELECTRIC 2

NO STOVE 3

OTHER 91

(SPECIFY)

REFUSED -7

DON’T KNOW -8

A13. I am going to read you a list of different kinds of smoke, not including tobacco, that you could have in your apartment. In the past 6 months, please tell me whether or not you had this source of smoke in your apartment unit.

	YES	NO	RE	DK
a) Propane/natural gas burning for example, stove, heater, dryer?	1	2	-7	-8
b) Smoke from cooking food?	1	2	-7	-8
c) Incense or candles?	1	2	-7	-8
d) Charcoal or wood burning?	1	2	-7	-8
e) Any other source? (SPECIFY)	1	2	-7	-8

A14. In the past 6 months, during a typical week, how often did anyone cook using a stove or oven in your apartment unit? Would you say…

Every day, 1

Several times a week, 2

Once a week, or 3

Less than once a week? 4

REFUSED -7

DON’T KNOW -8

Now I am going to ask you a few questions about odors coming into your apartment from the outdoors in the past 6 months.

A16. In the past 6 months, how often have you smelled the odor from a car, bus, truck, motorcycle or RV with a smoky exhaust in your apartment unit? Would you say…

Often, 1

Sometimes, 2

Rarely, or 3

Never? 4

REFUSED -7

DON’T KNOW -8

A17. In the past 6 months, how often did you smell cooking smoke in your apartment coming from grills or other outside sources? Would you say…

Often, 1

Sometimes, 2

Rarely, or 3

Never? 4

REFUSED -7

DON’T KNOW -8

SECTION B: SECONDHAND SMOKE EXPOSURE

Now I am going to ask you a few questions about your exposure to other people’s tobacco smoke. This could be inside your apartment or elsewhere in the apartment complex.

B1. In the past 6 months, how often has tobacco smoke drifted into your apartment unit from other units or from outside? Would you say…

Most days, 1

Some days, 2

Rarely, or 3

N ever? 4

REFUSED -7 GO TO B10

DON’T KNOW -8

B2. In the past 7 days, on how many days were you exposed to tobacco smoke drifting into your apartment unit?

NUMBER OF DAYS |___|___| (Range = 0-30)

REFUSED -7

DON’T KNOW -8

INTERVIEWER NOTE:

IF B2 = 0, GO TO B12.

B3. In the past 7 days, on average each day, about how long were you exposed to tobacco smoke drifting into your apartment unit? Would you say ...

Less than 10 minutes, 1

At least 10 minutes but less than 30 minutes, 2

At least 30 minutes but less than 1 hour, 3

1 to 3 hours, or 4

More than 3 hours? 5

REFUSED -7

DON’T KNOW -8

B4. Please tell me how you think tobacco smoke entered your apartment unit in the past 7 days? PROVIDE SHOW CARD.

[Did it enter your unit ...]	YES	NO	RE	DK
a) Through corridors/hallways?	1	2	-7	-8
b) Through cracks in the walls, floors, electric outlets, etc.?	1	2	-7	-8
c) Through an air heating or ventilation system?	1	2	-7	-8
d) Through unit patios, balconies and/or backyards?	1	2	-7	-8
e) Through open windows (other than those on patios, balconies or backyards) from outside common areas (for example, parking lot, pool area, shared patio area)?	1	2	-7	-8
f) Through other routes? (SPECIFY)	1	2	-7	-8
g) NO OTHER ROUTES	1	2	-7	-8

B5. In the past 7 days, what do you think were the sources of tobacco smoke entering your apartment? Was it ...

	YES	NO	RE	DK
a) A unit next to your home?	1	2	-7	-8
b) A unit above your home?	1	2	-7	-8
c) A unit below your home?	1	2	-7	-8
d) Nearby indoor common areas (for example, shared hallways, laundry rooms, lobby)?	1	2	-7	-8
e) Nearby outdoor common areas (for example, shared stairwells, pool area, parking lot)?	1	2	-7	-8
f) Other sources? (SPECIFY)	1	2	-7	-8
g) NO OTHER SOURCES	1	2	-7	-8

B6. In the past 7 days, what time of day did you typically smell tobacco smoke in your apartment? Would you say…

	YES	NO	RE	DK
a) Morning? [INTERVIEWER TO CONFIRM WITH RESPONDENT: “By morning, I mean 5:00 am to 11:59 am.”]	1	2	-7	-8
b) Afternoon? [INTERVIEWER TO CONFIRM WITH RESPONDENT: “By afternoon, I mean 12:00 pm to 4:59 pm.”]	1	2	-7	-8
c) Evening? [INTERVIEWER TO CONFIRM WITH RESPONDENT: “By evening, I mean 5:00 pm to 9:59 pm.”]	1	2	-7	-8
d) Night? [INTERVIEWER TO CONFIRM WITH RESPONDENT: “By evening, I mean 10:00 pm to 4:59 am”]	1	2	-7	-8

B7. In the past 7 days, in what rooms of your apartment unit did you typically smell tobacco smoke? Would you say you smelled it in the ….

	YES	NO	RE	DK	NA
a) Living room?	1	2	-7	-8	-9
b) Kitchen?	1	2	-7	-8	-9
c) Adult bedroom?	1	2	-7	-8	-9
d) Child’s bedroom?	1	2	-7	-8	-9
e) Bathroom?	1	2	-7	-8	-9
f) Hallway?	1	2	-7	-8	-9
g) Other rooms? (SPECIFY)	1	2	-7	-8	-9
h) NO OTHER ROOMS	1	2	-7	-8	-9

B8. In the past 7 days, how bothered were you when you were exposed to other people’s cigarette smoke inside your apartment unit? Would you say…

A lot, 1

Some, 2

A little, or 3

N ot at all? 4

REFUSED -7 GO TO B12

DON’T KNOW -8

B9. I am now going to ask you about some steps you might take to stop tobacco smoke from entering your apartment unit. Please tell me whether or not you used each of these in the past 7 days.

	YES	NO	RE	DK
a) Kept the windows or doors closed (including patio and/or balcony door)?	1	2	-7	-8
b) Put a towel under the door?	1	2	-7	-8
c) Sealed cracks in the walls, floors, electric outlets, etc.?	1	2	-7	-8
d) Turned on fan, air conditioner, or air purifier?	1	2	-7	-8
e) Other steps? (SPECIFY)	1	2	-7	-8

Now I am going to ask you a few questions about where you have smelled smoke in the last 7 days in the shared or common areas of your apartment complex. By common areas, I mean areas outside your apartment but inside your building, or areas outside the building, such as play areas, sidewalks, or parking lots, that residents share.

B10. In the past 7 days, please tell me whether or not you have smelled tobacco smoke in the following areas of your apartment complex?

	YES	NO	NOT APPLICABLE – NO SHARED AREA	RE	DK
a) Indoor shared hallways?	1	2	3	-7	-8
b) Indoor shared stairwells?	1	2	3	-7	-8
c) Shared laundry rooms?	1	2	3	-7	-8
d) Lobby and/or lounge area?	1	2	3	-7	-8
e) Recreation room and/or party room?	1	2	3	-7	-8

IF B10a-e = 2, GO TO B13.

B11. In the past 7days, on how many days did you smell tobacco smoke in the indoor shared areas -- for example, shared hallways, laundry rooms, lobby of your apartment complex?

NUMBER OF DAYS |___| (Range = 1-7)

N O DAYS 0

REFUSED -7 GO TO B13

DON’T KNOW -8

B12. In the past 7 days, on average each day, about how long did you smell tobacco smoke in the indoor shared areas (for example, shared hallways, laundry rooms, lobby) of your apartment complex? Would you say ...

Less than 10 minutes, 1

At least 10 minutes but less than 30 minutes, 2

At least 30 minutes but less than 1 hour, 3

1 to 3 hours, or 4

More than 3 hours? 5

REFUSED -7

DON’T KNOW -8

B13. In the past 7 days, on how many days did you smell tobacco smoke in the outdoor shared areas -- for example, shared patios, swimming pool, parking lot of your apartment complex?

NUMBER OF DAYS |___| (Range = 1-7)

N O DAYS 0

REFUSED -7 GO TO B15

DON’T KNOW -8

B14. In the past 7 days, on average each day, about how long did you smell tobacco smoke in the outdoor shared areas (for example, shared patios, swimming pool, parking lot) of your apartment complex? Would you say ...

Less than 10 minutes, 1

At least 10 minutes but less than 30 minutes, 2

At least 30 minutes but less than 1 hour, 3

1 to 3 hours, or 4

More than 3 hours? 5

REFUSED -7

DON’T KNOW -8

Now I am going to ask you a few questions about your contact with tobacco smoke in places other than your apartment complex.

B15. In the past 7 days, have you smelled or breathed in smoke in each of the following places?

	YES	NO	RE	DK	NA
a) Other people’s homes?	1	2	-7	-8	-9
b) Vehicles?	1	2	-7	-8	-9
c) Inside your workplace?	1	2	-7	-8	-9
d) Indoor entertainment venues (for example, bar, nightclub, cocktail lounge, sports arena, concert hall)?	1	2	-7	-8	-9
e) Outdoor waiting areas that are not part of your apartment complex (for example, bus stops, ATM, waiting lines)?	1	2	-7	-8	-9
f) Outdoor recreation areas located outside of your apartment complex (for example, parks, golf courses, sports fields)?	1	2	-7	-8	-9

Now I am going to ask about your experience in the last 6 months about smoke.

B16. In the past 6 months, how many times have you complained to the smoker(s) about the tobacco smoke entering your apartment?

NUMBER OF COMPLAINTS |___|___|___| (If no complaints, enter “0”)

REFUSED -7

DON’T KNOW -8

B17. In the past 6 months, how many times have you complained to building management about tobacco smoke entering your apartment?

NUMBER OF COMPLAINTS |___|___|___| (If no complaints, enter “0”)

REFUSED -7

DON’T KNOW -8

SECTION C: KNOWLEDGE, ATTITUDES, & BELIEFS ABOUT SECONDHAND SMOKE, HOUSING POLICY IMPLEMENTATION & ENFORCEMENT ISSUES

These questions will ask what you know about the apartment complex’s current policies on where people can or cannot smoke, and what your views are about those policies. There are no right or wrong answers. Please answer as fully as you can.

C1. Has building management prohibited smoking in the entire apartment complex, including all inside and outside areas?

YES 1

N O 2

REFUSED -7 GO TO C2

DON’T KNOW -8

C1a. Was the policy prohibiting smoking in the entire complex put into place in the past 6 months?

Y ES 1

NO 2 GO TO C3

REFUSED -7

DON’T KNOW -8

C2. Please tell me in which of the following areas of your apartment complex you think building management allows smoking. Is it allowed in ...

	YES	NO	RE	DK	NA
a) Shared outdoor areas (for example, patios, swimming pool, parking lot)?	1	2	-7	-8	-9
b) Shared indoor areas (for example, hallway, stairwells)?	1	2	-7	-8	-9
c) Inside the apartment units	1	2	-7	-8	-9
d) Patios, balconies, or backyards attached to the apartments) unit?	1	2	-7	-8	-9
e) Other areas? (SPECIFY)	1	2	-7	-8	-9

INTERVIEWER NOTE:

IF ALL OF C2a – e = NO, GO TO C5.

C3. Did management provide smoking cessation information and referrals to tenants who smoke?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

C4. There could have been a number of different reasons why management decided to prohibit smoking.

	YES	NO	RE	DK
a) Were any specific reasons given to tenants?	1	2	-7	-8
IF C4a = 2, GO TO C5

Please tell me whether or not you heard each of the following reasons.

b) Tenants requested it?	1	2	-7	-8
c) It would reduce costs when apartments had to be prepared for the next tenant?	1	2	-7	-8
d) It would improve safety by reducing the risk of fires?	1	2	-7	-8
e) Studies showed that it would improve health for tenants?	1	2	-7	-8
f) It was part of a decision to make the apartment complex more environmentally-friendly?	1	2	-7	-8
g) It is a new law in the city or state?	1	2	-7	-8
h) Other apartment owners and/or managers are voluntarily doing this in your city?	1	2	-7	-8
i) It is something your management company is implementing for all its properties, not just this one?	1	2	-7	-8
j) Some other reason? (SPECIFY)	1	2	-7	-8

C5. Do you think smoking should or should not be prohibited in each of the following areas of your apartment complex?

	SHOULD BE PROHIBITED	SHOULD NOT BE PROHIBITED	RE	DK
a) Inside all private units (not including private balconies, patios and backyards)?	1	2	-7	-8
b) All private balconies, patios and backyards?	1	2	-7	-8
c) All outdoor common/shared areas (for example, courtyards, swimming pools, parking lots)?	1	2	-7	-8
d) All indoor common/shared areas (for example, laundry rooms, lobby)?	1	2	-7	-8

C6. Please tell me how important you personally find each of the following arguments to be for having a smoke-free policy in your apartment complex. [Would you say ...

	Very Important	Somewhat Important	A Little Important	Not Very Important	RE	DK	NA
a) Tenants requested it?	1	2	3	4	-7	-8	-9
b) It would reduce costs when apartments had to be prepared for the next tenant	1	2	3	4	-7	-8	-9
c) It would improve safety by reducing the risk of fires?	1	2	3	4	-7	-8	-9
d) Studies showed that it would improve health for tenants?	1	2	3	4	-7	-8	-9
e) It was part of a decision to make the apartment complex more environmentally-friendly?	1	2	3	4	-7	-8	-9
f) It is a new law in the city or state?	1	2	3	4	-7	-8	-9
g) Other apartment owners and/or managers are voluntarily doing this in your city?	1	2	3	4	-7	-8	-9
h) It is something your management company is implementing for all its properties, not just this one?	1	2	3	4	-7	-8	-9
i) Some other reason? (SPECIFY)	1	2	3	4	-7	-8	-9

C7. Please tell me whether or not you believe that each of the following could help get all residents to obey smoke-free policies in your apartment complex. ?

	HELP	NOT HELP	RE	DK	N/A
a) Educating residents about the dangers of smoking (for example, it leads to diseases, causes fires)?	1	2	-7	-8	-9
b) Fines or evictions if residents don’t follow the policies?	1	2	-7	-8	-9
c) Fast response to resident complaints by building management?	1	2	-7	-8	-9
d) Educating and/or notifying residents about the smoke-free policy?	1	2	-7	-8	-9
e) Giving residents smoking cessation information or referrals to programs?	1	2	-7	-8	-9
f) Something else? (SPECIFY)	1	2	-7	-8	-9

INTERVIEWER NOTE:

IF ALL OF C2a – e = YES, GO TO C13. OTHERWISE, CONTINUE.

C8. Please tell me whether or not you believe each of the following prevents residents from obeying the smoke-free policies in your apartment complex. Would you say they don’t obey the policies because … ?

	YES	NO	RE	DK	N/A
a) Smoke-free policies are inconvenient to residents who smoke?	1	2	-7	-8	-9
b) There are weak or no consequences for ignoring the policies?	1	2	-7	-8	-9
c) There is no response to resident complaints from building management?	1	2	-7	-8	-9
d) There is poor education and/or notice about the smoke-free?	1	2	-7	-8	-9
e) Residents aren’t given smoking cessation information or referrals to programs?	1	2	-7	-8	-9
f) Other reason? (SPECIFY)	1	2	-7	-8

C9. Please tell me if you agree or disagree with each one of the following statements.

STATEMENT	AGREE	DISAGREE	RE	DK
a) I was involved in efforts to create the smoke-free policy in this apartment complex	1	2	-7	-8
IF C9a = 2, GO TO C9c
b) I felt that management listened to my opinion about the smoke-free policy in this apartment complex	1	2	-7	-8
c) My neighbors were involved in efforts create the smoke-free policy in this apartment complex	1	2	-7	-8

INTERVIEWER NOTE:

IF C9a OR C9c = AGREE, CONTINUE WITH C10. OTHERWISE, GO TO C11.

C10. I am going to read you a list of ways that tenants could have been involved in developing the current smoke-free policies. Please tell me whether or not each occurred at this apartment complex.

METHOD OF TENANT INVOLVEMENT	YES	NO	RE	DK
a) Meeting with tenants’ council?	1	2	-7	-8
b) Notice in tenants’ newsletter?	1	2	-7	-8
c) Letter to tenants?	1	2	-7	-8
d) Tenant survey?	1	2	-7	-8
e) Meeting with tenants?	1	2	-7	-8
f) Wrote the policy with tenants or tenants’ council?	1	2	-7	-8
g) Any other ways? (SPECIFY)	1	2	-7	-8

C11. Do you want to be involved in future decisions about the smoke-free policy in this apartment complex?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Now I’d like to ask some questions about moving to another apartment because of smoking issues.

C12. Have you ever decided to move out of your apartment because you were told that you or your guests couldn’t smoke inside your apartment?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

C13. Have you ever decided to move out of your apartment because your neighbors’ smoking exposed you to tobacco smoke in your home?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

INTERVIEWER NOTE:

IF SMOKING IN THE COMPLEX IS COMPLETELY BANNED (C1 = 1), GO TO C19.

C14. How likely are you to move out of your current apartment unit if a smoke-free policy in your building allowed existing tenants to continue smoking in their units? Would you say…

Not applicable-already prohibited in units, 1

Very likely, 2

Somewhat likely, or 3

Very unlikely? 4

REFUSED -7

DON’T KNOW -8

C15. How likely are you to move out of your current apartment unit if a smoke-free policy in your building allowed existing tenants to continue smoking in shared indoor areas -- for example, shared hallways, lobby, laundry rooms? Would you say…

Not applicable-already prohibited in shared indoor

areas, 1

Very likely, 2

Somewhat likely, or 3

Very unlikely? 4

REFUSED -7

DON’T KNOW -8

C16. How likely are you to move out of your current apartment unit if a smoke-free policy in your building allowed existing tenants to continue smoking in shared outdoor areas -- for example, shared patios, swimming pool, parking lot? Would you say…

Not applicable-already prohibited in shared outdoor

areas, 1

Very likely, 2

Somewhat likely, or 3

Very unlikely? 4

REFUSED -7

DON’T KNOW -8

C17. How much more rent per month, if any, would you be willing to pay for guaranteed smoke-free housing at this apartment complex? Would you say…

Not applicable – this is subsidized housing 1

I would not be willing to pay more rent, 2

Less than $100, 3

$100 to $299, 4

$300 to $499, or 5

$500 or more? 6

REFUSED -7

DON’T KNOW -8

C18. Given the opportunity, would you prefer to live in a complex where …

Smoking is not allowed anywhere -- that is,

common areas, individual units including

balconies, patios and/or backyards, 1

Smoking is only allowed in designated parts of

this apartment complex, or 2

Smoking is allowed anywhere in this apartment

complex? 3

OTHER 91

(SPECIFY)

REFUSED -7

DON’T KNOW -8

C19. What do you believe are the greatest obstacles to local government adopting and implementing a smoke-free MUH housing policy or law in this city?

C20. Which do you think are the least likely obstacles to overcome?

C21. What do you believe are the greatest obstacles to MUH complexes in attempting to adopt a voluntary-only smoke-free policy in this city?

C22. Which do you think are the least likely obstacles to overcome?

ONLY ASK QUESTION C23 AT FOLLOW-UP FOR INTERVENTION CITIES

C23. Are you aware that [NAME OF CITY] has adopted a policy prohibiting smoking in apartment complexes?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

SECTION D: SMOKING STATUS AND CESSATION BEHAVIORS AMONG RESIDENTS

In this part of the interview, I am going to ask you a few questions about your tobacco use in the past and the present.

D1. Have you smoked at least 100 cigarettes in your lifetime?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

D2. Do you now smoke cigarettes every day, some days, or not at all?

E VERY DAY 1 GO TO D4

SOME DAYS 2

N OT AT ALL 3

REFUSED -7 GO TO D13

DON’T KNOW -8

D3. In the past 30 days, on how many days did you smoke cigarettes?

SPECIFY NUMBER OF DAYS |___|___| (Range = 0-30)

REFUSED -7

DON’T KNOW -8

D4. In the past 30 days, on the days you smoked, about how many cigarettes did you smoke per day?

INTERVIEWER NOTE:

1 PACK = 20 CIGARETTES

SPECIFY NUMBER OF CIGARETTES |___|___|___| (Range = 0-100)

REFUSED -7

DON’T KNOW -8

D5. How much money do you spend in a typical week on cigarettes? Please give your best estimate to the nearest dollar amount.

DOLLAR AMOUNT $ |___|___|___|___| . |___|___|

DON’T BUY/GET FROM OTHERS 1

REFUSED -7

DON’T KNOW -8

D6. On a typical day that you smoke, how soon after you wake up do you smoke? Would you say…

Within 5 minutes, 1

From 6 to 30 minutes, 2

More than 30 minutes to an hour, or 3

More than an hour? 4

REFUSED -7

DON’T KNOW -8

D7. Are you seriously thinking of quitting smoking cigarettes?

YES 1

N O 2

REFUSED -7 GO TO D9

DON’T KNOW -8

D8. How soon are you seriously planning to quit smoking cigarettes? Would you say…

Within the next 30 days, 1

More than 30 days but within the next 6 months, 2

More than 6 months but within the next

12 months, or 3

No specific time? 4

REFUSED -7

DON’T KNOW -8

D9. During the past 6 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

YES 1

N O 2

REFUSED -7 GO TO D13

DON’T KNOW -8

D10. How long has it been since you last smoked a cigarette, even one or two puffs?

Within the past month (less than 1 month ago), 1

Within the past 3 months (1 month but less than

3 months ago), or 2

Within the past 6 months (3 months but less than

6 months ago)? 3

REFUSED -7

DON’T KNOW -8

D11. Now I am going to read you a list of products people have used to help them quit smoking. Please tell me whether or not you used each the last time you tried to quit smoking.

	YES	NO	RE	DK
a) A nicotine inhaler?	1	2	-7	-8
b) Nicotine lozenges?	1	2	-7	-8
c) Nicotine nasal spray?	1	2	-7	-8
d) Nicotine patch?	1	2	-7	-8
e) Nicotine prescription like Zyban, Wellbutrin, or Chantix?	1	2	-7	-8
f) Nicotine gum?	1	2	-7	-8

D12. How much money did you spend in a typical week on products to help you stop smoking? Please give your best estimate to the nearest dollar amount.

DOLLAR AMOUNT $ |___|___|___|___| . |___|___|

DON’T BUY/GET FROM OTHERS -1

REFUSED -7

DON’T KNOW -8

D13. Now I will read you a list of other tobacco products. Please tell me how often you currently use each of these products.

	[Every Day	Some Days	Not At All?]	RE	DK
a) Cigars (for example, cigarillos, little cigars)?	1	2	3	-7	-8
b) Pipes?	1	2	3	-7	-8
c) Hookahs/water pipes?	1	2	3	-7	-8
d) Electronic cigarettes (e-cigarettes)?	1	2	3	-7	-8
e) Smokeless tobacco products?	1	2	3	-7	-8

INTERVIEWER NOTE:

IF “NOT AT ALL” TO ALL OF D13a – e, GO TO SECTION E.

D14. Are you seriously thinking of quitting tobacco product use, other than cigarettes?

YES 1

N O 2

REFUSED -7 GO TO D16

DON’T KNOW -8

D15. How soon are you seriously planning to quit tobacco product use other than cigarettes? Would you say…

Within the next 30 days, 1

More than 30 days but within the next 6 months, 2

More than 6 months but within the next

12 months, or 3

No specific time? 4

REFUSED -7

DON’T KNOW -8

D16. During the past 6 months, have you stopped using tobacco products other than cigarettes for one day or longer because you were trying to quit?

YES 1

N O 2

REFUSED -7 GO TO SECTION E

DON’T KNOW -8

D17. How long has it been since you used a tobacco product other than cigarettes?

Within the past month (less than 1 month ago), 1

Within the past 3 months (1 month but less than

3 months ago), or 2

Within the past 6 months (3 months but less than

6 months ago)? 3

REFUSED -7

DON’T KNOW -8

D18. Now I am going to read you a list of products people have used to help them quit using tobacco. Please tell me whether or not you used each the last time you tried to quit using tobacco products other than cigarettes.

	YES	NO	RE	DK
a) A nicotine inhaler?	1	2	-7	-8
b) Nicotine lozenges?	1	2	-7	-8
c) Nicotine nasal spray?	1	2	-7	-8
d) Nicotine patch?	1	2	-7	-8
e) Nicotine prescription like Zyban, Wellbutrin, or Chantix?	1	2	-7	-8
f) Nicotine gum?	1	2	-7	-8

D19. How much money did you spend in a typical week on products to help you stop using tobacco, other than cigarettes? Please give your best estimate to the nearest dollar amount.

DOLLAR AMOUNT $ |___|___|___|___| . |___|___|

DON’T BUY/GET FROM OTHERS -1

REFUSED -7

DON’T KNOW -8

SECTION E: SMOKING-RELATED ILLNESSES

In this next set of questions, I will ask you about your general health, and then about some specific health problems you might have experienced. If there is a question that you don’t want to answer, please let me know and I will move on to the next question.

E1. Would you say that in general your health is…

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -7

DON’T KNOW -8

E2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

NUMBER OF DAYS |___|___|

NONE -1

REFUSED -7

DON’T KNOW -8

E3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

NUMBER OF DAYS |___|___|

NONE -1

REFUSED -7

DON’T KNOW -8

E4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

NUMBER OF DAYS |___|___|

NONE -1

REFUSED -7

DON’T KNOW -8

E5. About how much do you weigh without shoes? ROUND FRACTIONS UP.

INTERVIEWER NOTE:

IF RESPONDENT ANSWERS IN METRICS, PUT “9” IN COLUMN.

WEIGHT |___|___|___| (POUNDS/KILOGRAMS)

REFUSED -7

DON’T KNOW -8

E6. About how tall are you without shoes? ROUND FRACTIONS DOWN.

INTERVIEWER NOTE:

IF RESPONDENT ANSWERS IN METRICS, PUT “9” IN COLUMN.

HEIGHT |___|___| |___|___| _____________________

FT IN (METERS/CENTIMETERS)

REFUSED -7

DON’T KNOW -8

Now I am going to ask you about breathing symptoms you might have had in the past 4 weeks.

E7. Have you ever been diagnosed with asthma by a doctor, nurse, or other health professional?

YES 1

N O 2

REFUSED -7 GO TO E15

DON’T KNOW -8

E8. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

INTERVIEWER NOTE:

IF RESPONDENT DOESN’T KNOW AGE AT DIAGNOSIS, TRY TO DETERMINE IF AGE 10 OR YOUNGER OR 11 OR OLDER.

AGE IN YEARS |___|___| [96 = 96 and older]

IF UNABLE TO GIVE AGE IN YEARS, PROBE FOR APPROXIMATE AGE

AGE 10 OR YOUNGER -1

AGE 11 OR OLDER -2

REFUSED -7

DON’T KNOW -8

E9. During the past 6 months, have you had an episode of asthma or an asthma attack?

YES 1

N O 2

REFUSED -7 GO TO E15

DON’T KNOW -8

E10. During the past 6 months, how many times did you visit an emergency room or urgent care center because of your asthma?

NUMBER OF VISITS |___|___| [87 = 87 or more]

NONE -1

REFUSED -7

DON’T KNOW -8

E11. IF ONE OR MORE VISITS IN E10 STATE [“Besides those emergency room or urgent care center visits,”] During the past 6 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?

NUMBER OF VISITS |___|___| [87 = 87 or more]

NONE -1

REFUSED -7

DON’T KNOW -8

E12. During the past 6 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?

NUMBER OF VISITS |___|___| [87 = 87 or more]

NONE -1

REFUSED -7

DON’T KNOW -8

E13. During the past 6 months, how many days were you unable to work or carry out your usual activities because of your asthma?

NUMBER OF DAYS |___|___|___|

NONE -1

REFUSED -7

DON’T KNOW -8

Now we will talk about your asthma in the past 30 days.

E14. During the past 30 days, how often did you use a prescription asthma inhaler during an asthma attack to stop it?

INTERVIEWER NOTE:

HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.

READ ONLY IF NECESSARY:

Never (include no attack in past 30 days), 1

1 to 4 times (in the past 30 days), 2

5 to 14 times (in the past 30 days), 3

15 to 29 times (in the past 30 days), 4

30 to 59 times (in the past 30 days), 5

60 to 99 times (in the past 30 days), or 6

100 or more times (in the past 30 days)? 7

REFUSED -7

DON’T KNOW -8

Now I am going to ask you a few questions about other illnesses.

E15. Have you ever had a heart attack -- that is, acute myocardial infarction?

YES 1

N O 2

REFUSED -7 GO TO E18

DON’T KNOW -8

E16. Have you ever been hospitalized for a heart attack?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

E17. How many days of work have you ever missed due to a heart attack or heart attacks?

NUMBER OF DAYS |___|___|___| (Range = 0-183)

NONE 0

REFUSED -7

DON’T KNOW -8

E18. Have you ever had a stroke?

YES 1

N O 2

REFUSED -7 GO TO E21

DON’T KNOW -8

E19. Have you ever been hospitalized for a stroke?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

E20. How many days of work have you ever missed due to a stroke or strokes?

NUMBER OF DAYS |___|___|___| (IF NO DAYS, ENTER “0”)

REFUSED -7

DON’T KNOW -8

E21. Has a doctor, nurse, or other health professional ever told you that you had any of the following?

	YES	NO	RE	DK
a) Chronic obstructive pulmonary disorder or COPD?	1	2	-7	-8
b) Chronic sinusitis?	1	2	-7	-8
c) Allergies (for example, hay fever, seasonal, pet)?	1	2	-7	-8
d) Emphysema?	1	2	-7	-8

E22. Are you currently taking any medications for a respiratory condition, stroke, or a heart condition? Please include prescriptions and over the counter medications, medicine/supplements.

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

SECTION F: RESPONDENT CHARACTERISTICS

F1. What is your gender?

MALE 1

FEMALE 2

REFUSED -7

DON’T KNOW -8

F2. What is your date of birth?

|___|___| / |___|___| / |___|___|___|___|

MM DD YYYY

REFUSED -7

DON’T KNOW -8

F3. Are you of Latino or Hispanic origin?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

F4. Which race(s) do you identify with? (Respondent may select one or more from a-e; f is a recording option for the interviewer only)

	YES	NO	RE	DK
a) White?	1	2	-7	-8
b) Black/African-American?	1	2	-7	-8
c) Asian?	1	2	-7	-8
d) Native Hawaiian or Pacific Islander?	1	2	-7	-8
e) American Indian or Alaska Native?	1	2	-7	-8
f) Other race? (SPECIFY)	1	2	-7	-8

F5. What is the highest level of school you completed or highest degree you received?

8th grade or less, 1

Grades 9-12, 2

High school graduate/GED, 3

Some college/trade school/associates degree, 4

College graduate, or 5

Post-graduate degree? 6

REFUSED -7

DON’T KNOW -8

F6. What is your total monthly rent payment for this residence?

MONTHLY RENT

PAYMENT $ |___|___|___|___|.|___|___| (Range = $0-$5000.00)

REFUSED -7

DON’T KNOW -8

F6a. Does this include or exclude utilities?

INCLUDES UTILTIES 1

EXCLUDES UTILITIES 2

REFUSED -7

DON’T KNOW -8

F6b. What utilities are included in your rent?

	YES	NO	RE	DK
Water?	1	2	-7	-8
Gas?	1	2	-7	-8
Electric?	1	2	-7	-8
Something else? (SPECIFY)	1	2	-7	-8

F7. Now I am going to ask about the current total annual income for your household, including income from all sources such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Is it... PROVIDE SHOW CARD.

Less than $10,000, 1

$10,000 - $20,000, 2

$20,000 - $30,000, 3

$30,000 - $40,000, 4

$40,000 - $50,000, 5

$50,000 - $75,000, 6

$75,000 - $100,000, 7

100,000 - $150,000, or 8

More than $150,000? 9

REFUSED -7

DON’T KNOW -8

F8. Are you currently…? (123)

Employed for wages, 1

Self-employed, 2

Out of work for more than 1 year, 3

Out of work for less than 1 year, 4

A homemaker, 5

A student, 6

Retired, or 7

Unable to work? 8

REFUSED -7

DON’T KNOW -8

F9. Are you currently covered by any kind of health insurance?

YES 1

N O 2

REFUSED -7 GO TO G1

DON’T KNOW -8

F10. What type of health care coverage do you currently have? Do you have ...

	YES	NO	RE	DK
Private insurance coverage,	1	2	-7	-8
Medicare	1	2	-7	-8
Medi-Cal,	1	2	-7	-8
Military/VA,	1	2	-7	-8
Indian Health Service, or
Other type of health insurance? (SPECIFY)	1	2	-7	-8

SECTION G: CHILDREN’S MODULE

G1. Are you a parent, guardian, foster parent, or primary caregiver for the children who live in this apartment at least 20 hours a week?

YES 1  GO TO G3

NO 2

REFUSED -7

DON’T KNOW -8

G2. Is a parent, guardian, foster parent, or primary caregiver for these children available to talk now?

YES 1  REVIEW CONSENT AND

THEN GO TO G3

N O 2 END INTERVIEW AND

REFUSED -7 PROCEED TO VISUAL

DON’T KNOW -8 ASSESSMENT OF UNIT

INTERVIEWER NOTE:

HAVE CHILDREN’S PARENT, GUARDIAN, FOSTER PARENT, OR CAREGIVER READ AND COMPLETE 2 COPIES OF CONSENT FORM. SIGN BOTH COPIES, GIVE ONE COPY TO PARENT.

G3. Please tell me the names and birthdates of all the children under the age of 18 who live here at least 20 hours a week and for whom you are the parent, foster parent, or primary caretaker.

DESIGNATION	FIRST NAME	LAST NAME	DATE OF BIRTH MM/DD/YYYY
CHILD 1			|__|__| / |__|__| / |__|__|__|__|
CHILD 2			|__|__| / |__|__| / |__|__|__|__|
CHILD 3			|__|__| / |__|__| / |__|__|__|__|
CHILD 4			|__|__| / |__|__| / |__|__|__|__|
CHILD 5			|__|__| / |__|__| / |__|__|__|__|

Now I am going to ask you a few questions about your [child’s/children’s health]. [I will start by asking that question about the first child that you listed. Then I will repeat that same question for each of the other children you listed.]

NOTE TO INTERVIEWER:

FOR THE NEXT SERIES OF QUESTIONS, ASK ABOUT CHILDREN IN THE ORDER LISTED ABOVE. RECORD CHILD’S INITIALS OR FIRST NAME NEXT TO THE DESIGNATION NUMBER IN THE ROWS BELOW. DO NOT CHANGE THE ORDER IN WHICH EACH CHILD IS RECORDED]

G4. Would you say that in general [CHILD #1-5’s] health is…

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	GENERAL HEALTH					RE	DK
		Excellent	Very good	Good	Fair	Poor
CHILD 1		1	2	3	4	5	-7	-8
CHILD 2		1	2	3	4	5	-7	-8
CHILD 3		1	2	3	4	5	-7	-8
CHILD 4		1	2	3	4	5	-7	-8
CHILD 5		1	2	3	4	5	-7	-8

G5. Now thinking about [CHILD #1-5’s] physical health, which includes physical illness and injury, for how many days during the past 30 days was his/her physical health not good?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	NUMBER OF DAYS CHILD WAS NOT IN GOOD HEALTH IN LAST 30 DAYS (RECORD DAYS)	NONE	RE	DK
CHILD 1		|___|___|	0	-7	-8
CHILD 2		|___|___|	0	-7	-8
CHILD 3		|___|___|	0	-7	-8
CHILD 4		|___|___|	0	-7	-8
CHILD 5		|___|___|	0	-7	-8

G6. Has [CHILD #1-5] ever been diagnosed with asthma by a doctor, nurse, or other health professional?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	EVER DIAGNOSED WITH ASTHMA
CHILD 1		YES 1 N O 2 REFUSED -7 GO TO G16 DON’T KNOW -8
CHILD 2		YES 1 N O 2 REFUSED -7 GO TO G16 DON’T KNOW -8
CHILD 3		YES 1 N O 2 REFUSED -7 GO TO G16 DON’T KNOW -8
CHILD 4		YES 1 N O 2 REFUSED -7 GO TO G16 DON’T KNOW -8
CHILD 5		YES 1 N O 2 REFUSED -7 GO TO G16 DON’T KNOW -8

INTERVIEWER NOTE:

RECORD NAME/INITIAL BUT LEAVE ROW BLANK FOR ANY CHILD THAT DOES NOT HAVE DIAGNOSIS OF ASTHMA.

G7. How old was [CHILD #1-5] when he/she was first told by a doctor, nurse, or other health professional that he/she had asthma?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	AGE AT FIRST DIAGNOSIS (RECORD AGE IN YEARS)	RE	DK
CHILD 1		|___|___|	-7	-8
CHILD 2		|___|___|	-7	-8
CHILD 3		|___|___|	-7	-8
CHILD 4		|___|___|	-7	-8
CHILD 5		|___|___|	-7	-8

INTERVIEWER NOTE:

RECORD NAME/INITIAL BUT LEAVE ROW BLANK FOR ANY CHILD THAT DOES NOT HAVE DIAGNOSIS OF ASTHMA.

G8. During the past 6 months, has [CHILD #1-5] had an episode of asthma or an asthma attack?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	CHILD HAD ASTHMA ATTACK IN PAST 6 MONTHS
		YES	(IF “NO,” “RE,” OR “DK,” GO TO G16)
			NO	RE	DK
CHILD 1		1	2	-7	-8
CHILD 2		1	2	-7	-8
CHILD 3		1	2	-7	-8
CHILD 4		1	2	-7	-8
CHILD 5		1	2	-7	-8

THE NEXT QUESTIONS APPLY ONLY TO CHILDREN WHO HAD ASTHMA SYMPTOMS IN THE PAST SIX MONTHS.

G9. During the past 6 months, how many times did [CHILD #1-5] visit an emergency room or urgent care center because of his/her asthma?

G10 [Besides those emergency room or urgent care center visits] During the past 6 months, how many times did [CHILD #1-5] see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?

G11. During the past 6 months, how many times did [CHILD #1-5] see a doctor, nurse, or other health professional for a routine checkup for his/her asthma?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G9. NUMBER OF ER OR URGENT CARE VISITS FOR ASTHMA IN PAST 6 MONTHS	G10. NUMBER OF URGENT TREATMENT OF ASTHMA IN PAST 6 MONTHS	G11. NUMBER OF ROUTINE CHECKUPS FOR ASTHMA IN PAST 6 MONTHS
CHILD 1		|___|___|___| (times) NONE …… -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 2		|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 3		|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 4		|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 5		|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8	|___|___|___| (times) NONE -1 REFUSED -7 DON’T KNOW -8

G12. In the past 6 months, how often did [CHILD #1-5’s] asthma limit (his/her) physical activity?

G13. In the past 6 months, how many days of daycare or school did [CHILD #1-5] miss due to asthma?

G14. Of the days that [CHILD #1-5] missed daycare or school, how many of those days did you miss work to take care of him/her?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G12. HOW OFTEN CHILD’S ASTHMA LIMITS HIS/HER ACTIVITIES	G13. NUMBER OF DAYS IN PAST 6 MONTHS (RECORD NUMBER OF DAYS)	G14. NUMBER OF ADULT WORK DAYS MISSED FOR CHILD’S ASTHMA IN PAST 6 MONTHS (RECORD NUMBER OF DAYS)
CHILD 1		Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 REFUSED -7 DON’T KNOW -8	|___|___|___| (DAYS) N ONE -1 GO REFUSED -7 TO DON’T KNOW -8 G15	|___|___|___| (DAYS) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 2		Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 REFUSED -7 DON’T KNOW -8	|___|___|___| (DAYS) N ONE -1 GO REFUSED -7 TO DON’T KNOW -8 G15	|___|___|___| (DAYS NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 3		Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 REFUSED -7 DON’T KNOW -8	|___|___|___| (DAYS) N ONE -1 GO REFUSED -7 TO DON’T KNOW -8 G15	|___|___|___| (DAYS) NONE -1 REFUSED -7 DON’T KNOW -8
CHILD 4		Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 REFUSED -7 DON’T KNOW -8	|___|___|___| (DAYS) N ONE -1 GO REFUSED -7 TO DON’T KNOW -8 G15	|___|___|___| (DAYS) NONE -1 REFUSED -7 DON’T KNOW -8

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G12. HOW OFTEN CHILD’S ASTHMA LIMITS HIS/HER ACTIVITIES (CHECK ONE)	G13. NUMBER OF DAYS IN PAST 6 MONTHS (RECORD NUMBER OF DAYS)	G14. NUMBER OF ADULT WORK DAYS MISSED FOR ASTHMA’S ASTHMA IN PAST 6 MONTHS (RECORD NUMBER OF DAYS)
CHILD 5		Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 REFUSED -7 DON’T KNOW -8	|___|___|___| (DAYS) N ONE -1 GO REFUSED -7 TO DON’T KNOW -8 G15	|___|___|___| (DAYS) NONE -1 REFUSED -7 DON’T KNOW -8

INTERVIEWER NOTE:

RECORD NAME/INITIAL, BUT LEAVE ROW BLANK FOR ANY CHILD THAT DOES NOT HAVE DIAGNOSIS OF ASTHMA.

G15. During the past 30 days, how often did [CHILD #1-5] use a prescription asthma inhaler during an asthma attack to stop it?

INTERVIEWER NOTE:

HOW OFTEN (NUMBER OF TIMES) DOES NOT EQUAL NUMBER OF PUFFS. TWO TO THREE PUFFS ARE USUALLY TAKEN EACH TIME THE INHALER IS USED.

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	NUMBER OF DAYS CHILD USED PRESCRIPTION INHALER DURING ASTHMA ATTACK TO STOP ATTACK IN PAST 30 DAYS
CHILD 1		Never 1 1-4 times (in past 30 days) 2 5-14 times (in past 30 days) 3 15-29 times (in past 30 days) 4 30-59 times (in past 30 days) 5 60-99 times (in past 30 days) 6 100 or more times (in past 30 days) 7 REFUSED -7 DON’T KNOW -8
CHILD 2		Never 1 1-4 times (in past 30 days) 2 5-14 times (in past 30 days) 3 15-29 times (in past 30 days) 4 30-59 times (in past 30 days) 5 60-99 times (in past 30 days) 6 100 or more times (in past 30 days) 7 REFUSED -7 DON’T KNOW -8
CHILD 3		Never 1 1-4 times (in past 30 days) 2 5-14 times (in past 30 days) 3 15-29 times (in past 30 days) 4 30-59 times (in past 30 days) 5 60-99 times (in past 30 days) 6 100 or more times (in past 30 days) 7 REFUSED -7 DON’T KNOW -8
CHILD 4		Never 1 1-4 times (in past 30 days) 2 5-14 times (in past 30 days) 3 15-29 times (in past 30 days) 4 30-59 times (in past 30 days) 5 60-99 times (in past 30 days) 6 100 or more times (in past 30 days) 7 REFUSED -7 DON’T KNOW -8
DESIGNATION	CHILD’S INITIALS OR FIRST NAME	NUMBER OF DAYS CHILD USED PRESCRIPTION INHALER DURING ASTHMA ATTACK TO STOP ATTACK IN PAST 30 DAYS (CHECK ONE)
CHILD5		Never 1 1-4 times (in past 30 days) 2 5-14 times (in past 30 days) 3 15-29 times (in past 30 days) 4 30-59 times (in past 30 days) 5 60-99 times (in past 30 days) 6 100 or more times (in past 30 days) 7 REFUSED -7 DON’T KNOW -8

INTERVIEWER NOTE:

ASK G16 OF ALL CHILDREN IN HOME.

G16. Is [CHILD #1-5] currently taking any medications for a respiratory condition, asthma, or respiratory allergies? Please include prescriptions and over the counter medications, medicine/supplements.

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	CHILD TAKES MEDICINES FOR RESPIRATORY CONDITION, ASTHMA, OR RESPIRATORY ALLERGIES
CHILD 1		YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 2		YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 3		YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 4		YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 5		YES 1 NO 2 REFUSED -7 DON’T KNOW -8

Now I would like to ask some questions about [CHILD #1-5’s] experiences with tobacco smoke.

G17. To your knowledge, does [CHILD #1-5] (if older than age 8) smoke cigarettes or use other tobacco products?

G18. To your knowledge, did the mother of [CHILD #1-5] smoke cigarettes at any time when she was pregnant with [CHILD #1-5]?

G19. At any time during the mother of [CHILD #1-5’s] pregnancy, did she stop smoking for one day or longer because she was trying to quit?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G17. CHILD OLDER THAN AGE 8 SMOKES OR USES TOBACCO PRODUCTS	G18. PARENT SMOKED WHEN PREGNANT	G19. PARENT STOPPED SMOKING FOR AT LEAST ONE DAY WHILE PREGNANT WITH CHILD
CHILD 1		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	YES 1 N O 2 GO REFUSED -7 TO DON’T KNOW -8 G20	YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 2		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	YES 1 N O 2 GO REFUSED -7 TO DON’T KNOW -8 G20	YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 3		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	YES 1 N O 2 GO REFUSED -7 TO DON’T KNOW -8 G20	YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 4		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	YES 1 N O 2 GO REFUSED -7 TO DON’T KNOW -8 G20	YES 1 NO 2 REFUSED -7 DON’T KNOW -8
CHILD 5		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	Y ES 1 NO 2 GO REFUSED -7 TO DON’T KNOW -8 G20	YES 1 NO 2 REFUSED -7 DON’T KNOW -8

Now I am going to ask you a few questions about THE CHILDREN’S contact with smoke from other people.

G20. In the past 7 days, on how many days did [CHILD #1-5] experience tobacco smoke in your apartment unit –-- whether the smoke came from inside the apartment, other neighboring apartments, or from the outside?

G21. In the past 7 days, on average each day, about how long was [CHILD #1-5] in contact with tobacco smoke in your apartment unit?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G20. CHILD EXPOSED TO TOBACCO SMOKE IN APARTMENT (RECORD DAYS)	G21. HOW LONG ON AVERAGE DAY WAS CHILD EXPOSED TO TOBACCO SMOKE IN APARTMENT
CHILD 1		|___|___| (1-7 DAYS) N OT EXPOSED 0 GO REFUSED -7 TO DON’T KNOW -8 G22	Less than 10 min 1 At least 10 min but less than 30 minutes 2 At least 30 min but less than 1 hour 3 1-3 hours 4 More than 3 hours 5 Not exposed 6 REFUSED -7 DON’T KNOW -8
CHILD 2		|___|___| (1-7 DAYS) N OT EXPOSED 0 GO REFUSED -7 TO DON’T KNOW -8 G22	Less than 10 min 1 At least 10 min but less than 30 minutes 2 At least 30 min but less than 1 hour 3 1-3 hours 4 More than 3 hours 5 Not exposed 6 REFUSED -7 DON’T KNOW -8
CHILD 3		|___|___| (1-7 DAYS) N OT EXPOSED 0 GO REFUSED -7 TO DON’T KNOW -8 G22	Less than 10 min 1 At least 10 min but less than 30 minutes 2 At least 30 min but less than 1 hour 3 1-3 hours 4 More than 3 hours 5 Not exposed 6 REFUSED -7 DON’T KNOW -8

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G20. CHILD EXPOSED TO TOBACCO SMOKE IN APARTMENT (RECORD DAYS)	G21. HOW LONG ON AVERAGE DAY WAS CHILD EXPOSED TO TOBACCO SMOKE IN APARTMENT
CHILD 4		|___|___| (1-7 DAYS) N OT EXPOSED 0 GO REFUSED -7 TO DON’T KNOW -8 G22	Less than 10 min 1 At least 10 min but less than 30 minutes 2 At least 30 min but less than 1 hour 3 1-3 hours 4 More than 3 hours 5 Not exposed 6 REFUSED -7 DON’T KNOW -8
CHILD 5		|___|___| (1-7 DAYS) N OT EXPOSED 0 GO REFUSED -7 TO DON’T KNOW -8 G22	Less than 10 min 1 At least 10 min but less than 30 minutes 2 At least 30 min but less than 1 hour 3 1-3 hours 4 More than 3 hours 5 Not exposed 6 REFUSED -7 DON’T KNOW -8

G22. In the past 7 days, has [CHILD #1-5] been exposed to tobacco smoke in the following situations?

	CHILD’S INITIALS OR FIRST NAME	G22a. IN OTHER PEOPLE’S HOMES	G22b. IN A VEHICLE	G22c. AT DAYCARE OR SCHOOL	G22d. AT INDOOR WORK- PLACE	G22e. AT INDOOR ENTER- TAINMENT VENUE	G22f. AT OUTDOOR WAITING AREA	G22g. AT OUTDOOR REC-REATION AREA
CHILD 1		Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8
CHILD 2		Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8
CHILD 3		Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8
CHILD 4		Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8
CHILD 5		Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8	Yes 1 No 2 Refused -7 Don’t Know -8

Now I am going to ask you a few questions about [CHILD #1-5’s] demographics.

G23. Is [CHILD #1-5] of Latino or Hispanic origin

G24. Which of the following race(s) does [CHILD #1-5] identify with?

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G23. CHILD OF LATINO OR HISPANIC ORIGIN?	G24. CHILD’S RACIAL BACKGROUND
CHILD 1		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	White?  Black/African-American?  Asian?  Native Hawaiian or Pacific Islander?  American Indian or Alaska Native?  Other race?  (SPECIFY) REFUSED  DON’T KNOW 
CHILD 2		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	White?  Black/African-American?  Asian?  Native Hawaiian or Pacific Islander?  American Indian or Alaska Native?  Other race?  (SPECIFY) REFUSED  DON’T KNOW 
CHILD 3		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	White?  Black/African-American?  Asian?  Native Hawaiian or Pacific Islander?  American Indian or Alaska Native?  Other race?  (SPECIFY) REFUSED  DON’T KNOW 

DESIGNATION	CHILD’S INITIALS OR FIRST NAME	G23. CHILD OF LATINO OR HISPANIC ORIGIN?	G24. CHILD’S RACIAL BACKGROUND
CHILD 4		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	White?  Black/African-American?  Asian?  Native Hawaiian or Pacific Islander?  American Indian or Alaska Native?  Other race?  (SPECIFY) REFUSED  DON’T KNOW 
CHILD 5		YES 1 NO 2 REFUSED -7 DON’T KNOW -8	White?  Black/African-American?  Asian?  Native Hawaiian or Pacific Islander?  American Indian or Alaska Native?  Other race?  (SPECIFY) REFUSED  DON’T KNOW 

Thank you for your time. I would now like to take a brief look around the living room and kitchen.

RESIDENT SURVEY VISUAL ASSESSMENT

PART A: UNIT ASSESSMENT

(TO BE COMPLETED AFTER RESIDENT INTERVIEW)

Water/Mold

1. Water Stains/Water Damage (Excludes Visible Mold):

≥4 square feet water stains/water

damage: Any one ceiling, floor,

or wall has evidence of water

stains/water damage, a leak

(such as a darkened area) over

a large area (4 square feet or

more). Water may or may not

be visible 1

<4 square feet water stains/

water damage: Any one ceiling,

floor, or wall has evidence of

water stains/water damage, a

leak (such as a darkened area)

over a small area (less than 4

square feet). Water may or may

not be visible 2

No water stains/water damage 3

2. Mold:

≥4 square feet visible mold

present or musty odor detected:

Any one ceiling, floor, or wall

has visible mold over a large

area (4 square feet or more)

R-A musty odor is detected 1

<4 square feet visible mold

present: Any one ceiling, floor,

or wall has visible mold over a

small area (less than 4 square

feet) 2

No mold observed or musty odor

detected 3  GO TO 4

2a. Mold Source: CHECK ALL THAT APPLY

Leaking roof 

Leaking appliance 

Leaking water pipe in wall or

ceiling 

Condensation 

None 

UNABLE TO OBSERVE 

3. Moldy or Musty Odor Present:

Yes 1

No 2  GO TO 4

3a. Record location:

Living Room 

Kitchen 

4. Sources of Excessive Humidity:

Yes: Sources of humidity

(e.g., humidifier, dryer

vented inside, uncovered

fish tank) present 1

No: Sources of humidity

(e.g., humidifier, dryer

vented inside, uncovered

fish tank) not present 2 GO TO 5

UNABLE TO OBSERVE -7

4a. If yes, record source and location:

Living Room 

Kitchen 

Heating/Cooling

5. Primary heating source for unit:

Radiators 1

Electric space heater 2

Forced hot air (vents) 3

Open oven 4

Kerosene space heater 5

Fireplace/wood-burning stove 6

No heating source observed 7

6. Primary cooling source for unit:

Central air 1

Window air conditioning units 2

Ceiling fans 3

Table or floor-level oscillating

fans 4

Open windows only source of

cooling 5

No cooling source observed 6

7. HVAC General Rust/Corrosion:

Significant rust/corrosion:

Significant deterioration from

rust and corrosion on HVAC

units in the dwelling unit (includes

ducts, radiators, baseboard

heaters, etc.) 1

Surface rust/corrosion:

Deterioration from rust and

corrosion on HVAC units in

the dwelling unit (includes

ducts, radiators, baseboard

heaters, etc.) 2

No rust/corrosion in HVAC units

in the dwelling unit (includes

ducts, radiators, baseboard

heaters, etc.) 3

UNABLE TO OBSERVE -7

8. HVAC Operation:

Not working: HVAC system

does not function; it does not

provide the heating or cooling

it should 1

The system does not respond

when the controls are engaged 2

Working 3

UNABLE TO OBSERVE -7

9. HVAC Filters

Need replacement 1

Clean 2

Not applicable 3

UNABLE TO OBSERVE -7

10. Space Heaters:

Space heaters used in unit are

not at least 3 feet from anything

that can burn 1

Space heaters used in unit are

at least 3 feet from anything

that can burn 2

Not applicable: No space heaters

used in unit 3

UNABLE TO OBSERVE -7

11. Fireplace Screen:

Fireplace does not have a

sturdy screen to catch

sparks 1

Fireplace has a sturdy

screen to catch sparks 2

N ot applicable: No

fireplace in unit 3 GO TO

UNABLE TO OBSERVE -7 13

12. Fireplace Dampers:

Fireplace dampers not

operational 1

Fireplace dampers operational 2

Not applicable: No fireplace in

unit 3

UNABLE TO OBSERVE -7

13. Unvented Combustion Appliances:

Yes: Unvented combustion

appliances (e.g., fuel-fired space

heaters, gas clothes dryers, gas

logs, charcoal, stoves etc.)

present 1

No: Unvented combustion

appliances (e.g., fuel-fired

space heaters, gas clothes

dryers, gas logs, charcoal,

stoves etc.) not present 2

UNABLE TO OBSERVE -7

13a. If yes, record type and number:

Type:

Number:

Type:

Number:

Water Heater

14. Water Heater Exhaust:

Electrical hot water or heater

used instead of gas-fired or

oil-fired unit 1

No water heater inside unit 2

Misaligned: Any misalignment

that may cause improper or

dangerous venting of gases 3

Not misaligned 4

UNABLE TO OBSERVE -7

15. Leaks:

Water leak observed 1

No water leak observed 2

UNABLE TO OBSERVE -7

Laundry Area [observed only if connected to living room or kitchen]

16. Clothes Dryer:

Vent missing: Dryer vent to

outside is missing 1

Vent damaged: Dryer exhaust

is not effectively vented to

the outside because of

blockage or inadequate design

or is vented into the interior 2

Vent not missing or damaged:

Exhaust vent is functioning

properly 3

No dryer 4  GO TO 19

UNABLE TO OBSERVE -7

17. Exhaust Duct From Dryer:

Flexible plastic: Dryer exhaust

duct is made of flexible plastic 1

Flexible metal: Dryer exhaust

duct is made of flexible metal 2

Other: Wood or other

combustible material 3

Rigid metal: Dryer exhaust duct

is made of rigid metal 4

UNABLE TO OBSERVE -7

Not applicable -9

18. Dryer Venting:

Dryer vents to basement 1

Dryer vents to attic 2

Dryer vents to crawl space 3

Dryer vents to living space 4

Dryer vents to outside 5

Other 91

(SPECIFY)

Not applicable -9

UNABLE TO OBSERVE -7

Flooring/Doors/Windows

19. Living Room Flooring:

Permanent carpet on living room

floor (does not include

removable mats) 1

Living room floor is a hard,

cleanable surface 2

20. Entry Door Seals:

Entry door seals deteriorated/

missing: The seals are missing

on one or more entry door(s),

or they are so damaged that

they do not function as they

should 1

No damage observed 2

21. Windows:

One or more windows missing 1

One or more windows cracked

or broken 2

One or more windows cannot be

opened 3

All windows intact and can be

opened 4

22. Window Sills:

Missing or damaged: A sill is

missing or damaged, but the

inside of the surrounding wall is

not exposed and is still

weathertight 1

Not weathertight: A sill is missing

or damaged enough to expose

the inside of the surrounding

wall and compromise its

weather tightness 2

Not missing or damaged 3

23. Interior Window Caulking/Seals:

Missing/deteriorated (leaks

present): There is missing or

deteriorated caulk or seals and

evidence of leaks or damage to

the window or surrounding

structure 1

Missing/deteriorated (no leaks):

There is missing or deteriorated

caulk on windows, but there is no

evidence of damage to the

window or surrounding structure 2

Not missing/deteriorated 3

24. Condensation on Windows:

Condensation on windows,

doors, walls 1

No condensation on windows,

doors, walls 2

25. Windows/Doors open during interview:

Yes, window to exterior open 1

Yes, door to exterior open 2

No doors or windows open 3

Hazardous Materials

26. Chemicals, Pesticides, Cleaning Supplies, or Medications Stored Within Easy Reach of Children

Yes 1

N o 2

Not applicable, no children in GO TO

household 3 27

UNABLE TO OBSERVE -7

26a. If yes, record type and location:

Type:

Number:

Type:

Number:

Pest Hazards

27. Infestation - Roaches:

Frass or shells 

One or more live roaches 

N o roaches or roach evidence  GO TO

UNABLE TO OBSERVE  28

27a. If roach evidence present, record location(s):

28. Infestation - Rats or Mice:

Droppings or chewed holes 

One or more rats/mice 

No rats/mice/droppings/holes 

UNABLE TO OBSERVE 

28a. If rat or mouse evidence present, record location(s):

29. Other Insects or Vermin:

Yes: Other insects or vermin

seen 1

No: Other insects or vermin not

seen 2

UNABLE TO OBSERVE -7

29a. If yes, record type and location(s) type:

30. Visible Dust on Surfaces:

Heavy 1

Slight 2

No visible dust on surfaces 3

General

31. Garbage:

Garbage and debris not properly

stored: Missing, uncovered, or

leaking container 1

Garbage and debris properly

stored 2

32. Air Cleaning Device Present:

Yes 1

No 2

UNABLE TO OBSERVE -7

33. Ozone Generator Present:

Yes 1

No 2

UNABLE TO OBSERVE -7

34. Pets Present:

Yes 1

No 2

UNABLE TO OBSERVE -7

34a. If yes, record type and number of pet(s):

Type:

Number:

Type:

Number:

35. Tobacco Smoke or Odor Present:

Yes 1

No 2

36. Ashtrays present:

Yes, present but empty 1

Yes, present and cigarette butts

or ashes observed 2

No 3

37. Candles, incense, or air fresheners present:

Yes, observed, but not in use 1

Yes, observed but in use 2

Not observed 3

38. Vacuum cleaner present:

Yes, observed, but not working 1

Yes, observed and functional 2

Yes, observed but not tested 3

UNABLE TO OBSERVE -7

Kitchen

39. Range or Stove:

Stove and/or oven missing 1

Two or more burners not working

Gas ranges: flames not

distributed equally or pilot lights

out on two or more burners

Electric ranges: two or more

heating elements (including the

oven) not working 2

Gas ranges: flames not

distributed equally or pilot lights

out on one burner

Electric ranges: one heating

element (including the oven)

not working 3

Stove and oven working 4

UNABLE TO OBSERVE -7

40. Range Hood:

Not working: Range hood does

not turn on 1

Partial blockage: An accumulation

of dirt threatens the free passage

of air -OR-Flue completely

blocked 2

No range hood/exhaust fan 3

No blockage/functional: Range

hood works properly 4

UNABLE TO OBSERVE -7

41. Type of Cooking occurring during visit: CHECK ALL THAT APPLY

None 

Baking 

Frying 

Broiling 

Grilling 

Toasting 

UNABLE TO OBSERVE 

42. Kitchen Flooring:

Permanent carpet on kitchen

floor (does not include

removable mats) 1

Kitchen floor is a hard, cleanable

surface 2

UNABLE TO OBSERVE -7

Thank you for your time and your help with today’s survey. Here is your gift card(s). Please sign two copies of this receipt, and I will give you one for your records.

RESIDENT SURVEY VISUAL ASSESSMENT

PART B: INTERIOR ASSESSMENT

(TO BE COMPLETED AFTER RESIDENT INTERVIEW)

	Common Area 1 ______________________ (Location)	Common Area 2 ______________________ (Location)	Common Area 3 ______________________ (Location)
Moldy or Musty Odor Present
Yes 1	1	1	1
No 2	2	2	2
Tobacco Smoke or Odor Present
Yes 1	1	1	1
No 2	2	2	2
“No smoking” signage in common area
Yes 1	1	1	1
No 2	2	2	2
Ashtrays present in common area
Yes, present but empty 1	1	1	1
Yes, present and cigarette butts or ashes observed 2	2	2	2
No 3	3	3	3

	Common Area 1 ______________________ (Location)	Common Area 2 ______________________ (Location)	Common Area 3 ______________________ (Location)
Trash Collection Areas
Trash on floor: Extensive trash and/or garbage on the floor 1	1	1	1
Trash containers/chutes missing covers: Missing or damaged covers to trash chutes or trash or garbage containers 2	2	2	2
Both: Both trash on floor and missing or damaged covers 3	3	3	3
No trash on floor or missing covers 4	4	4	4
No trash collection area observed 5	5	5	5
UNABLE TO OBSERVE -7	-7	-7	-7
Water Stains/Water Damage - Ceilings
≥2 square feet: One or more ceilings(s) has evidence of a leak, water damage, or water staining (such as a darkened area) over a large area (more than 4 square feet) 1	1	1	1
<2 square feet: One or more ceiling(s) has evidence of a leak, water damage, or water staining (such as a darkened area) over a small area (less than 4 square feet) 2	2	2	2
No water stains/water damage 3	3	3	3
UNABLE TO OBSERVE -7	-7	-7	-7

	Common Area 1 ______________________ (Location)	Common Area 2 ______________________ (Location)	Common Area 3 ______________________ (Location)
Waters Stains/Water Damage - Floors
≥4 square feet: A large portion of one of more floors (more than 4 square feet) has been substantially saturated or damaged by water, mold, or mildew. Cracks, mold, and flaking are seen; the floor surface may have failed 1	1	1	1
<4 square feet: Evidence of a water stain (such as a darkened area) over a small area of floor (less than 4 square feet). Water may or may not be seen. Less than 10% of the floors are affected 2	2	2	2
No water stains/water damage 3	3	3	3
UNABLE TO OBSERVE -7	-7	-7	-7
Waters Stains/Water Damage - Walls
≥4 square feet: A large portion of one of more walls (more than 4 square feet) has been substantially saturated or damaged by water, mold, or mildew. Cracks, mold, and flaking are seen; the wall may have failed 1	1	1	1
<4 square feet: Evidence of a water stain (such as a darkened area) over a small area of wall (less than 4 square feet). Water may or may not be seen. Less than 10% of the walls are affected 2	2	2	2
No water stains/water damage 3	3	3	3
UNABLE TO OBSERVE -7	-7	-7	-7

	Common Area 1 ______________________ (Location)	Common Area 2 ______________________ (Location)	Common Area 3 ______________________ (Location)
Mold
≥4 square feet visible mold present or musty odor detected: Any one ceiling, floor, or wall has visible mold over a large area (4 square feet or more) R-A musty odor is detected 1	1	1	1
<4 square feet visible mold present: Any one ceiling, floor, or wall has visible mold over a small area (less than 4 square feet) 2	2	2	2
No mold observed or musty odor detected 3	3	3	3
UNABLE TO OBSERVE -7	-7	-7	-7

RESIDENT SURVEY VISUAL ASSESSMENT

PART C: EXTERIOR ASSESSMENT

(TO BE COMPLETED AFTER RESIDENT INTERVIEW)

1. Address:

Street

City State Zip

2. Type of Building in which Unit is Located:

Duplex 1

Triplex 2

Townhome 3

Low-rise (1–3 floors) 4

High-rise (4+ floors) 5

3. Number of Units in Building: (Count mailboxes if necessary)

Number of Units: |___|___|___|

4. Building’s Proximity to Traffic:

Building borders on busy highway 1

Building borders on busy public street 2

Building borders on quiet public street 3

Building has private entrance 4

5. Building Foundation Cracks/Gaps:

≥1/8 inches wide × 1/8 inches deep × 6

inches long: Cracks more than 1/8 inch

wide by 1/8 inch deep by 6 inches long

OR-Large pieces—many bricks, for

example - are separated or missing from

the wall or floor OR-Large cracks or gaps

(a possible sign of a serious structural

problem) – OR-Cracks run the full depth

of the wall, providing opportunity for water

penetration -OR-Sections of the wall or

floor are broken apart 1

<1/8 inches wide × 1/8 inches deep × 6 inches

long: Cracks smaller than these dimensions 2

No cracks/gaps: No signs of deterioration 3

6. Window Panes:

One or more missing or broken: A glass pane

is missing -OR-A glass pane is cracked or

broken AND sharp edges are seen 1

Both broken and missing: More than one

window has broken and missing glass panes 2

One or more cracked: A glass pane is cracked

but no sharp edges are seen 3

None broken, cracked, or missing 4

51