Enrollment - mother

Prospective Birth Cohort Study Involving Environmental Uranium Exposure in the Navajo Nation

Att8b Mother Enroll

Enrollment Survey - mother

OMB: 0923-0046

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Shape1

Form Approved:

OMB No. 0923-0046

Exp. Date 02/29/2016

Shape2 Participant Number: Survey Version _1_

Navajo Birth Cohort Study

ENROLLMENT SURVEY FOR MOTHERS

Date of Interview:

_I_n_t_e_r_v_i_e_w_er_N_a_m_e:

_Loca_t_i_on_o_f_I_n_t_e_r_v_i_e_w_:

RECORD OF CONSENT

If participant is under the age of 18 years a PARENTAL CONSENT TO PARTICIPATE IN RESEARCH with a parent’s and participant signature must be on file before proceeding any further.

I am going to read and explain two documents, called “Consent to Participate in Research” and “HIPAA Form”.

[Read the Consent Form. Make sure the participant initials each page and obtain participant's signature on the form before proceeding. Hand the participant a copy of the Consent Form after he or she has signed the original. You, the Interviewer, will keep the original signed consent form. Make sure the HIPAA and release forms are signed also.]

Was the “Consent to Participate in Research/HIPAA Form” read / explained in:

 Navajo  English  Combination of both

Did the person consent to participate?  Yes  No

If “yes”, proceed with administration of the survey. If “no”, thank them for their time.

INTRODUCTION

If participant consented at an earlier time, start here. This is to ensure that they still qualify to be a participant in the study.

Are you still pregnant?  Yes  No  Don’t Know

[If “no”, go to sympathy statement and thank them for their time.] Would you like to be interviewed in the Navajo or English language?

 Navajo  English  Combination of both

Is there any change in your contact information since we last spoke to you?

 Yes  No  Don’t Know

CONTACT INFORMATION

_M_a_ili_ng_A_dd_r_ess

_T_e_l_ephone_N_u_m_ber
–_H_o_m_e

_C_e_l_l

_M_essa_g_e

E-mail address

Public reporting burden of this collection of information is estimated to average 120 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0046).

Shape4 Participant Number: Survey Version _1_

Navajo Birth Cohort Study

ENROLLMENT SURVEY FOR MOTHERS

The purpose of this study is to look into community concerns about whether exposure to uranium mining and milling waste affects the outcome of pregnancies and the development of Navajo children. The proposed research will provide a public health benefit through education on environmental prenatal risks and provide earlier assessment and referral for identified developmental delays. Finally, the results of this study will provide the first Navajo-Nation-wide documentation of birth outcomes and developmental delays. Information gathered and analyzed will be provided to the tribe and Navajo

Area Indian Health Service which may be used to improve future birth outcomes and services.

Before we begin the questionnaire, do you think your baby’s father would be willing to participate in the study with you and your baby?

 Yes

 No

 Don’t know

 Refused

If the father of your baby is a minor (less than 18 years old), his parents must be contacted and consent to his being in the study. How old is your baby’s father?

 Less than 18 years old

 Greater than 18 years old

 Don’t know

 Refused

If you have not talked with the father of your baby about participating in the study would you like to speak with him before we contact him?

 Yes

 No

 Don’t know

 Refused

Are you willing to give us the name of the father of your baby, so that we may contact him and ask if he is willing to participate in the Navajo Birth Cohort Study?

 Yes

 No

 Don’t know

 Refused

If you don’t mind if we contact him, please provide his name and contact information below: Name

_P_hone_nu_m_b_e_r

_Loca_t_i_on_o_f_h_o_m_e

Shape5 Participant Number: Survey Version _1_

_DE_M_O_GR_A_PH_I_CS

1. What is your date of birth?

/ / MM DD YYYY

2. Where were you born?

City or town State

_C_oun_tr_y

3. What language do you speak most often?

3a. At work?  English  Navajo  Both  Other

3b. At home with family?  English  Navajo  Both Other

3c. With friends?  English  Navajo  Both Other

4.Are you married or living with a partner?  Yes  No

4.a. If no, are you: Never married or lived with partner

 Separated from husband or partner

 Divorced

 Widowed

5. What is the highest grade of school you have completed or the highest degree you have received?

__N_o_educ_a_t_i_on

_₁^st_t_o₆^th_g_r_a_de

_₇^th_t_o₉^th_g_r_ade

 10^thto 12^thgrade, no diploma

 High school graduate/GED

 Bachelor’s degree

 Some college, no degree

 Associate degree

 Graduate or professional degree

 Other specify

 Don’t know

 Refused

6. Are you currently a student?  Yes  No

7. What is your current paid employment status?

 Unemployed

 Self-employed

 Employed part-time

__E_m_p_l_o_y_ed_f_u_l_l_-_t_i_m_e

Shape6 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

8. What is your best estimate of your total personal income from all sources in the past year (before taxes)? If annual income not known, ask “What is your best estimate of your monthly income?” and choose from the choices below.

 Less than or equal to $4,999 per year ($417 monthly)

 $5,000 - $9,999 per year ($418 – $833 monthly

 $10,000 - $19,999 per year ($834 - $1666 monthly)

 $20,000 - $39,999 per year ($1667 – $3333 monthly)

 $40,000 - $69,999 per year ($3334 – $5833 monthly)

 More than $70,000 per year ($5834 monthly)

 Don’t Know

 Refused

9. Household income means income for everyone in your household, taken together. What is your best estimate of your total household income before taxes from all sources in the past year?

 Less than or equal to $4,999 per year ($417 monthly)

 $5,000 - $9,999 per year ($418 – $833 monthly

 $10,000 - $19,999 per year ($834 - $1666 monthly)

 $20,000 - $39,999 per year ($1667 – $3333 monthly)

 $40,000 - $69,999 per year ($3334 – $5833 monthly)

 More than $70,000 per year ($5834 monthly)

 Don’t Know

 Refused

Now, I am going to ask you a few questions about your baby’s father.

10. Would you be willing to answer these questions?  Yes  No  Refused

(If refused, go to Reproductive History- Question 15)

11. Is your baby’s father Navajo? -  Yes  No

12. If not, what is the race or ethnicity of your baby’s father? (Check all that apply) African American or black  Yes  No

American Indian or Alaska Native  Yes  No

Asian  Yes  No Hispanic  Yes  No Native Hawaiian or Other Pacific Islander  Yes  No White  Yes  No

_Ot_h_e_r_,
spec_i_f_y

__Y_es__No

Don’t know  Yes  No

Refused  Yes  No

13. What is the highest grade of school you have completed or the highest degree you have received?

__N_o_educ_a_t_i_on

_₁^st_t_o₆^th_g_r_a_de

_₇^th_t_o₉^th_g_r_ade

 10^thto 12^thgrade, no diploma

 High school graduate/GED Bachelor’s degree

 Some college, no degree

 Associate degree

 Graduate or professional degree

 Other specify

__D_on_’_t
know

Shape7 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

REPRODUCTIVE HISTORY

14. How old were you when you had your first menstrual period? | | |

............................................................................. AGE IN YEARS

15. Before you became pregnant, what was the usual pattern of your menstrual cycles (when not pregnant or breastfeeding or using birth control pills)?

 Always irregular

 Usually irregular

 Regular (within 5-7 days of expected)

 Very regular (within 3-4 days of expected)

 Extremely regular (no more than 1-2 days before or after expected)

 Don’t know

 Refused

16. Have you ever used birth control pills?  Yes  No  Refused

17. What is your usual form of birth control? Choose only one answer.

 None

 Rhythm method or counting of days in cycle

 Condom or other barrier method (diaphragm or cervical cap)

 IUD (intrauterine device)

 Birth control pills

 Birth control patch (Ortho-Evra) or ring (Nuvaring)

 Birth control shots (Depo Provera) or injectable estrogen (Lunelle)

 Other Specify

 Refused or don’t know

18. How old were you at your first pregnancy?

| | |  Refused

AGE IN YEARS

19. Besides your current pregnancy, how many pregnancies have you had?

| | |.........................................................  Refused

NUMBER

20. Have you ever had a miscarriage (spontaneous abortion)?

 Yes

 No

 Don’t know

 Refused

21. Have you ever had a still-born child (baby was not alive at birth)?

 Yes

 No

 Don’t know

__R_e_f_used

Shape8 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

22. How many live-born children have you had? ........................

| | | Refused

NUMBER

23. Have any of your children been diagnosed with developmental delay, a birth defect or immune system problems?

 Yes

 No

 Don’t know

 Refused

If yes please start with oldest child and work your way to the youngest…

Gender Date of Birth Diagnoses Receiving Care Where

Shape9 _C_h_il_d_#1.__B_oy__G_i_r_l_/_/

Shape10 _C_h_il_d_#2.__B_oy__G_i_r_l_/_/

Shape11 _C_h_il_d_#3.__B_oy__G_i_r_l_/_/

Shape12 _C_h_il_d_#4.__B_oy__G_i_r_l_/_/

Shape13 _C_h_il_d_#5.__B_oy__G_i_r_l_/_/

Shape14 _C_h_il_d_#6.__B_oy__G_i_r_l_/_/

24. Have you ever delivered or received prenatal care in any the following health-care facilities?

 Chinle Comprehensive Health Care Facility

 Ft. Defiance Indian Hospital

 Gallup Indian Medical Center

 Kayenta Health-Center

 Northern Navajo Medical Center (i.e., Shiprock Hospital)

 Tuba City Regional Health-Care Corporation

 Other

25. Have you ever breastfed your children for more than two weeks?

 Yes→ If yes, specify below the number of months breastfed FOR EACH CHILD

 No - This is my first baby.

 No - I have not breastfed any of my other children.

 Refused

Start with your oldest child and work your way to the youngest…

Gender Date of Birth Number of Months Breastfed

_C_h_il_d_#1.__B_oy__G_i_r_l_/_/

_C_h_il_d_#2.__B_oy__G_i_r_l_/_/

_C_h_il_d_#3.__B_oy__G_i_r_l_/_/

_C_h_il_d_#4.__B_oy__G_i_r_l_/_/

_C_h_il_d_#5.__B_oy__G_i_r_l_/_/

Child #6.  Boy Girl / /

Shape15 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

26. Have you ever carried a pregnancy with multiple babies (twins, triplets, etc.)?  Yes  No

27. Have you or your partner sought treatment for fertility concerns?  Yes  No

28. Have you ever taken fertility medications? (such as hormone treatments)  Yes  No

_CURRE_N_T_PRE_G_N_A_N_C_Y_I_N_F_O_R_M_A_T_IO_N

29. What is your due date? / / DD MM YYYY

30.Do you know if you are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

 Don’t know

 Singleton

 Twins

 Triplets or Higher

 Refused

31. Are you getting prenatal care?  Yes  No  Refused

Shape16 _31a._I_f_“_y_es_,_”_w_he_r_e_a_r_e_y_ou_g_e_t_t_i_ng_p_r_en_a_t_al
c_a_r_e?

NAME OF PRENATAL CLINIC

31b. How many weeks pregnant were you when you had you first prenatal clinic visit?

| | | .......................................  Don’t know

NUMBER OF WEEKS

32. Are you receiving prenatal care from a traditional practitioner?  Yes  No

33. What was your weight before you became pregnant? ........... | | | |  Don’t know

............................................................................. POUNDS  Refused

34. In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

 Yes

 No

 Don’t know

 Refused

35. Do you plan to breastfeed your new baby?

 Yes

 No

 Don’t know

__R_e_f_used

Shape17 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

36. Are you currently receiving WIC assistance?

 Yes

 No

 Don’t know

__R_e_f_used

CURRENT MEDICATION AND SUBSTANCE USE

37. Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

 Yes

 No

 Don’t know

 Refused

38. Are you currently taking doctor-prescribed medications and/or vitamins on a daily basis?

 Yes →What [prescribed] medications do you take?

_38a.

_38b.

_38c.

_38d.

__No

38e.

39. Are you currently taking over-the-counter (non-prescription) medications and/or vitamins on a daily basis?

 Yes →What [over the counter medications] do you take?

_39a.

_39b.

_39c.

_39d.

__No

39e.

40. Are you currently taking herbal supplements on a daily basis?

 Yes →What herbal supplements do you take?

_40a.

_40b.

_40c.

_40d.

__No

40e.

Shape18 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

41. Are you currently using any traditional or home remedies?

 Yes →What remedies do you take?

_41a.

_41b.

_41c.

_41d.

__No

41e.

42. It often takes a few months to find out you are pregnant. During that period when you didn’t know you were pregnant, is it possible you may have used any of the following?

 Marijuana

 Street or recreational drugs such as cocaine, ecstasy, methamphetamine

 Alcohol (including beer)

43. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctor’s prescription for?

 Yes → 43a. How many times?

 Once or twice

10 or more times

 Don’t know

__R_e_f_used

 No

44. Are you currently smoking marijuana?

 Yes

 No

 Refused

45. Are you currently using other recreational or street drugs, including drugs that you smoke or inject?

Yes →What drugs are they?

_45a.

_45b.

_45c.

_45d.

__No

45e.

Shape19 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

46. Have you ever tried or used any other recreational drugs, including illicit or street drugs or drugs that you did not have a doctor’s prescription for?

 Yes → 46a. How many times?

 Once or twice

 10 or more times

 Don’t know

__R_e_f_used

__No

ALCOHOL USE

47. How often did you have a drink containing alcohol in the past year?

 Never

 Monthly or less

 Two to four times a month

 Two to three times a week

 Four or more times a week

48. How many drinks containing alcohol did you have on atypical day when you were drinking in the past year?

 0 drinks

 1 or 2

 3 or 4

 5 or 6

 7 to 9

49. How often did you have six or more drinks on one occasion in the past year?

 Never

 Less than monthly

 Monthly

 Weekly

 Daily or almost daily

TOBACCO USE

50. Do you smoke tobacco only for ceremonial use?

 Yes → [skip to 59]

 No

51. In your lifetime, have you smoked as many as 100 cigarettes?

 Yes

 No→ [skip to 59]

52. Was there ever a time that you smoked at least 1 cigarette a day for a month or longer?

 Yes

 No→ [skip to 59]

53. Do you now smoke cigarettes (not including those for ceremonial use only)?

 Yes

__No

Shape20 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

54. For about how many years total would you say that you smoked at least 1 cigarette per day?

| | | .................................................  Don’t Know

YEARS

55. During the time you smoked at least 1 cigarette a day, about how many cigarettes a day on average?

| | _|

cigarettes/day .........................................  Don’t Know

56. When was your last cigarette?

 Today

 In the past week

 More than a week ago

 More than a month ago

 Before pregnancy

 Don’t know

 Refused

57. Did you ever quit smoking for 6 months or longer?

 Yes → If Yes: 57a. Did you quit because of your pregnancy?

 Yes

__No

No

58. If you stopped smoking cigarettes and then started smoking again, for how many years did you quit?

\| \| \|	\| \| \|	 Don’t Know
months quit	years quit

59. Does anyone else in your household smoke on a daily basis?

 Yes

 No

 Don’t know

 Refused

If yes 59a. How often do household members or guests smoke cigarettes in your home?

 Daily

 Weekly

 Monthly

STRESS

The following questions ask about your feelings and thoughts during the last month. In each case, please tell me how often you felt or thought a certain way.

60. During the last 30 days, about how often did you feel so depressed that nothing could cheer you up?

 All of the time

 Most of the time

 Some of the time

 A little of the time

__N_one_o_f_t_he_t_i_m_e

Shape21 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

61. During the last 30 days, about how often did you feel hopeless?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

62. During the last 30 days, about how often did you feel restless or fidgety?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

63. During the last 30 days, about how often did you feel that everything was an effort?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

64. During the last 30 days, about how often did you feel worthless?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

65. During the last 30 days, about how often did you feel nervous?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

PHYSICAL ACTIVITY

66. During the past month, other than for your regular job, did you participate in any physical activities, such as running, gardening, aerobics, dancing, basketball, walking for exercise, herding sheep, chopping wood, or horseback riding?

 Yes

 No

 Don’t know

 Refused

67. How often do you exercise? (Such as the activities above)

 Once or more per week

 Once per month

 On occasion

__N_e_v_er

Shape22 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

68. What is your primary mode of transportation?

 Car

 Bus

 Hitchhiking

 Horseback

 Walking

__Ot_h_e_r_S_pec_i_f_y

HOUSING CHARACTERISTICS

69. What is the location of your home?

Shape23 [The participant may give his or her house number and street/road name, rural address, nearest highway or natural feature, or distance from Chapter House.]

70. Is the house you are living in…?

 Owned or being bought by you or someone in your household

 Rented by you or someone in your household, or

 Some other arrangement

 Don’t know

 Refused

71. Can you tell us, which of these categories do you think best describes when your home or building was built?

 2001 TO present

 1981 TO 2000

 1961 TO 1980

 1941 TO 1960

 1940 or before

 Don’t know

 Refused

72. How long have you lived in this home?

| | |  Weeks

NUMBER ....  Months

.........  Years

.........  Don’t know

.........  Refused

73. What type of home do you live in?

 Hogan

 Modular or site-built house

 Mobile home

 Multi-family dwelling or Apartment building

 Seasonal camp or lodging

 Hotel /motel or other temporary housing

 Other Specify

 Don’t know

__R_e_f_used

Shape24 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

74. What is the construction of your home? (Check all that apply)

 Mobile home

 Wood frame

 Stone

 Adobe

 Crawlspace or basement

 Dirt floor

75. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, tarps, utility poles, railroad ties, or other materials from an abandoned uranium mine or mill?

__Y_es

__N_o

75a.If yes which materials were used  Wood

 Sheet metal

 Metal pipes

 Rocks

 Sand

 Tarps

 Utility poles

 Railroad ties

 Other:

 Don’t know

 Refused

76. Does your home contain any wood, sheet metal, metal pipes, rocks, sand, utility poles, railroad ties, or other materials from oil and gas operations?

__Y_es

__N_o

76a.If yes which materials were used  Wood

 Sheet metal

 Metal pipes

 Rocks

 Sand

 Utility poles

 Railroad ties

 Other:

 Don’t know

 Refused

77. Including yourself, how many people live in your home?

| | | NUMBER

78. Excluding bathrooms, how many total rooms are in your home?

| | | NUMBER

79. Which of these types of heat /fuel sources do you use to heat your home?

 Electric

 Gas-Natural

__G_as_-_P_r_opane_o_r_LP

Shape25 Participant Number: Survey Version _1_

 Oil

 Wood

 Kerosene or diesel fuel

 Coal

 Solar energy

 Wind power

 No heating source

 Other specify

 Don’t know

 Refused

79a.If you burn wood or coal in your home, what is the approximate age of your stove.

 1-5 yrs

 5-10 yrs

 10-15 yrs

 >15 yrs

79b.If you burn wood or coal in your home, how often do you personally tend the fire?

 Once per day

 1-5 x per day or more

 Once per week

 1-3 times per week

 Occasionally

80. How do you cool your home? SELECT ALL THAT APPLY.

 Fan

 Window or wall air conditioners

 Central air conditioning

 Evaporative cooler (swamp cooler)

 No cooling or air conditioning used

 Other specify

 Don’t know

 Refused

81. In the past 12 months, have you seen any water damage inside your home?

 Yes

 No

 Don’t know

 Refused

82. In the past 12 months, have you seen any mold or mildew on walls or other surfaces inside your home?

 Yes

 No

 Don’t know

 Refused

83. Since you became pregnant, have any additions been built onto your home to make it bigger, or have any renovations or other construction been done in your home? Include all projects such as painting, wallpapering, carpeting or re-finishing floors.

 Yes

 No

 Don’t know

__R_e_f_used

Shape26 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

84. Do you have any pets that spend any time inside your home?

 Yes

 No

 Don’t know

 Refused

85. What kind of pets are these? SELECT ALL THAT APPLY.

 Dog

__C_at

85a. Do you change the cat box?  Yes  No

 Lambs or baby goats

 Small mammal (rabbit, gerbil, hamster, guinea pig, ferret)

 Bird (including chicks)

 Fish or reptile (turtle, snake lizard)

 Other specify

 Don’t know

 Refused

86. Do you tend livestock on a regular basis in a corral or around your home?

 Yes

 No

87. Please tell us all the places you have lived throughout your life, even as a child, and how long you lived at each place.

Chapter

Location Description

# of years

| | |

WATER USAGE

88. Is your home connected to a community water system piped in to your home?

 Yes  No  Don’t Know

_88a_._I_f_y_es,_w_hat_i_s_t_he_n_a_m_e_o_f_t_he_w_a_t_er
s_y_s_t_e_m_?

88b.If yes, is this your main source of drinking water?  Yes  No  Don’t Know

Shape27 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

89. Do you haul water?  Yes  No  Refused

89a.If you haul water, what type of container do you use to haul water?

 Plastic

 Metal

 Glass

 Wood

 Other Specify

 Don’t know

89b.If you haul water, where do you haul water from? [Check all that apply]

 Lake/pond

 Stream/river

 Spring

 Rain Water

 Irrigation Water

 Cistern or tank at windmill

 Windmill

 Private well

 Grocery or convenience store/ trading post

 Navajo Tribal Utility Authority (NTUA) or other public water supply

 Other Specify

 Don’t know

89c. If yes, in what types of containers do you store this hauled water?

 Plastic

 Metal

 Glass

 Wood

 Concrete

 Other Specify

 Don’t know

89d.If you haul water, do you filter the water you haul?

 Yes

If yes, what filters do you use?

 Charcoal filter

 Ceramic filter

 Distillation

 Boil

 Disinfect

 No, don’t do anything to the water

 Don’t know

89e. How many places do you currently haul water from? | | |

_{............................................................................}_._N_U_M_BER

Shape28 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

90. Using the map, can you identify the location of any water sources from which you or someone in your household has hauled water for drinking or other household use?

Please note all uses of this water for each source identified.

Name/Number of Uses of the water (drinking, cooking, livestock Number of years

_W_a_t_e_r_S_ou_r_ce_w_a_t_e_r_i_n_g_,_i_rr_i_g_a_t_i_on,
ba_t_h_i_ng,_o_t_her
househo_l_d_use_s₎

_|_|_|

| | |

91. What water source in your home do you use most of the time for drinking?

 Hauled water

 Tap or piped in water

 Filtered tap/piped in water

 Bottled water

 Other specify

 Don’t know

 Refused

92. What water source in your home is used most of the time for cooking?

Shape37  Hauled water

 Tap or piped in water

 Filtered tap/piped in water

 Bottled water

 Other specify

 Don’t know

 Refused

FOOD BEHAVIORS

93. Do you eat the meat of the livestock you raise?  Yes  No  Don’t know

Shape38 _93a_._W_he_r_e_do_t_he_li_v_es_t_ock_g_r_a_z_e?₍_U_s_i_ng_m_a_p_,_l_o_ca_t_e_g_r_a_z_i_ng_a_r_ea)

Shape39 Shape40 Shape41 _93b_._W_he_r_e_do_t_hey_g_et_w_a_t_e_r_?₍_U_s_i_ng_m_a_p_,_l_oc_a_t_e_w_e_ll_s,_sp_r_i_n_g_s_,_pon_d_s,_e_t_c_.₎

Shape42 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

94. Please tell us what animals you eat and the specific parts you eat, including the organs.

 Sheep/Goat  Cattle  Horse  Pig  Chicken  Turkey

 Muscle  Liver  Kidney  Brain  Intestine  Testicles

__T_o_n_g_ue__H_ea_r_t__Ot_h_e_r

94a. In the last month, have you eaten any food that was blackened, charred, or roasted through cooking?  Yes  No

94b. If yes, how many servings?

 1-2  3-5  6-10  11-19  20+

95. Do you eat the vegetables or fruit you grow? Yes No  Don’t know

96. Do you use the water you haul for the vegetables you grow? Yes No  Don’t know

_97._Pl_ease_t_e_l_l
us_w_hat_v_e_g_e_t_ab_l_es_or_fr_u_i_t_s_t_h_a_t_y_ou_g_r_ow_and_e_a_t_:

 Apples	 Apricots  Beans	 Bell Peppers	 Carrots	 Chile
 Corn	 Cucumbers Melons	 Onions	 Peaches	 Potatoes
 Squash	 Strawberries	 Tomatoes

 Other

98. Do you gather and eat vegetation from the wild?

__Y_es

__No

If Yes  Wild Onions

 Wild Carrots

 Wild Berries

 Cedar tree berries

 Pinõn nuts

 Yucca Fruit

 Others:

 Don’t know

 Refused

99. Are you receiving WIC?

Yes No  Don’t know

99a. If yes skip to Occupational and Environmental History.

_99b._I_f_no_g_o_t_o_Food_F_r_e_q_uency_Q_ues_t_i_ons
or_m_a_k_e_f_o_ll_o_w_-_up_appo_i_n_tm_e_n_t

_D_a_t_e

_T_i_m_e

_Loc_a_t_i_on

_O_CCUPA_T_IO_NA_L

OCCUPATIONAL AND ENVIRONMENTAL HISTORY

100. Have you ever been employed outside of the home?

 Yes

 No

__R_e_f_used

Shape43 Shape44 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

If no, skip this section

_I_f_y_es,_p_l_ease_an_s_w_e_r_t_he_f_o_ll_o_w_i_n_g_:

101. At any of your jobs, have you ever handled or come into contact with pesticides (bug or weed spray), other chemicals, or toxic or potentially dangerous substances?

 Yes

 No

 Don’t know

 Refused

101a.If yes, complete the following

Shape45 Shape46 Substance Brand/Name Used Indoor Used outdoors How Long

Shape47 _P_es_t_i_c_i_de

Shape48 _C_he_m_i_ca_l_s

Shape49 Shape50 _Ot_h_e_r

102. Have you worked in any of the following industries outside your home? If yes, how long (years)?

Shape51 Number of Years

Shape52  Gold and/or silver mining ............................................ | | |

 Coal mining ................................................................ | | |

 Uranium mining / milling ............................................. | | |

 Uranium reclamation................................................... | | |

 Uranium ore hauling ................................................... | | |

 Other mining (e.g., copper, iron, lead, vanadium) ...... | | |

 Petroleum or natural gas production .......................... | | |

 Electronics manufacturing .......................................... | | |

 Plastics manufacturing ............................................... | | |

 Gold/Silversmithing..................................................... | | |

 Roadwork/paving ....................................................... | | |

 Military (depleted uranium, high explosives) ............... | | |

 Electric/transmission line/Utility crew | | |

 Pottery ....................................................................... | | |

 Lapidary...................................................................... | | |

__W_e_a_v_i_ng_{....................................................................}_._|_|_|

Shape53 Participant Number: Survey Version _1_

 Livestock (herding, transporting, working in a feed-yard) | | |

 Other Specify | | |

103. Have you or anyone in your household done any of the following activities in your home?

_I_f_y_es,
how_l_ong₍_y_ea_r_s₎_?

Number of Years

 Electronics | | |

 Plastics | | |

 Gold/Silversmithing | | |

 Pottery | | |

 Lapidary | | |

 Weaving | | |

 Other Specify | | |

104. If you do lapidary work in your home, do you use

 Block or synthetic stones

 Stabilized stones

 Only natural stone

 Don’t know

105. If you make jewelry in your home, do you use solder?

 Yes

 No

 Don’t know

 Refused

_ENV_I_R_O_N_M_EN_T_A_L

106. Have you ever lived near an agricultural area or farm?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 106a. Number of years | | | 106b. Where?

 No

 Don’t know

107. Have you ever lived near a toxic waste site or waste dump or landfill?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 107a. Number of years | | | 107b. Where?

 No

__D_on_’_t
know

Shape54 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

Shape55 108. Have you ever lived near a chemical factory or plant?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

__Y_es_→₁₀₈_a_._N_u_m_ber_o_f_y_ea_r_s_|_|_|₁_08b._W_he_r_e?

Shape56 _108c_._C_h_e_m_i_ca_l_s_used_o_r_m_an_u_f_ac_t_u_r_ed_t_h_e_r_e

 No

 Don’t know

109. Have you ever lived near a uranium mine?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 109a. Number of years | | | 109b. Where?

 No

 Don’t know

110. Have you ever lived near a uranium mill?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 110a. Number of years | | | 110b. Where?

 No

 Don’t know

111. Did either of your parents or grandparents work in a uranium mine or mill?

 Yes

 No

 Don’t know

111a. If yes

Shape57 Shape58 Shape59 Shape60 Shape61 Shape62 _N_a_m_e_o_f_M_i_ne_or_M_i_l_l_N_u_m_ber_o_f_Y_ea_r_s_w_o_r_ked_t_h_e_r_e

112. Did anyone in your household work in a uranium mine or mill at any time during your lifetime?

Shape63  Yes

 No

Shape64 Shape65  Don’t know

_112a_._I_f_y_es

Shape66 Shape67 Shape68 Shape69 Shape70 _N_u_m_ber_o_r_y_ea_r_s_Y_our_a_g_e_a_t_t_he_t_i_m_e

Shape71 22

Shape72 _P_ar_t_i_c_i_pan_t_N_u_m_ber_:_S_urve_y_V_e_r_s_i_o_n_{_}₁_{_}

113. Can you think of any other ways you might have come in contact with uranium, such as:

113a. Playing on a uranium tailings pile or waste dump?

 Yes  No

113b. Playing outdoors near or next to a uranium mine, mill or waste dump?

 Yes  No

113c. Drinking, wading into or coming into contact with uranium mine water or waste spills?

 Yes  No

113d. Herding livestock on or next to a uranium mine, mill or waste dump?

 Yes  No

113e.Sheltering livestock in an abandoned mine?

 Yes  No

113f. Living in a mining camp?

 Yes  No

113g.Washing or handling clothes of a friend or family member who was a uranium worker?

 Yes  No

113h. Live in the same home with a uranium miner or miller?

 Yes  No

114. Have you ever lived near an oil and gas facility, such as a oil or natural gas well, petroleum refinery, natural gas plant or natural gas compressor station?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 114a. Number of years | | | 114b. Where?

 No

 Don’t know

115. Have you ever lived near a coal-fired electric generating station, coal waste dump or coal mine (surface or underground)?

By “near,” I mean downwind of, along a road, in a floodplain, or within two miles

 Yes → 115a. Number of years | | | 115b. Where?

 No

 Don’t know

_T_H_A_N_K
YOU_F_OR
YO_U_R_P_A_RT_I_C_I_P_A_T_I_ON

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