Form 13 Attachment 19-1 BEEA CAPI Questionnaire

Attachment 19-1: BEEA Home Visit CAPI (Random Select and Recent Exposed Groups)
Study of Biomarkers of Exposures and Effects in Agriculture
Agricultural Health Study
Location of Residence (County, State): ___________________
Date: _____/______/______
MM

DD

YYYY

OMB #: 0925-0406
Expiration date: 09/30/2016
Collection of this information is authorized by The Public Health Service Act (42 USC 285l). Rights of study
participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not
participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way.
The information collected in this study will be kept private to the extent provided by law. Names and other identifiers
will not appear in any report of the study. Information provided will be combined for all study participants and reported
as summaries. You are being contacted by mail to complete this health follow-up survey because as a member of the
Agricultural Health Study your continued involvement can help us learn more about how agricultural and
environmental factors may affect the health of farmers and their families.
Public reporting for this collection of information is estimated to average 90 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0406). Do not return the completed form to this address.

PRE-INTERVIEW PREPARATION:
1. ASK PARTICIPANT FOR SHOWCARD WITH PESTICIDE INFORMATION.
2. ASK PARTICIPANT FOR ASSEMBLED PRESCRIPTION MEDICATIONS.
3. PROVIDE CALENDAR TO PARTICIPANT FOR REFERENCE.
[Display subject ID and Participant information on CAPI “face sheet”]
Screening Questions To Ask Prior To Consent (SCR):
1a. Is your name ^DSP.Respondent_Fullname and is your date of birth ^STN.Respondent_Birthdate?
Yes _____ (Q2) No _____
1b. What is your correct date of birth? ______/_______/________
MM

DD

YYYY

1c. [INTERVIEWER] IS IT POSSIBLE THAT THE NUMBERS IN THE DATE OF BIRTH FROM
OUR RECORDS (BIRTHDATE), COMPARED TO THE BIRTHDATE GIVEN (RESPONDENT
BIRTHDATE) COULD HAVE BEEN TRANSPOSED, MISREAD, OR ARE REVERSED?
YES _____ (Q2a) NO _____
1d. Does another person with a similar name but a different date of birth live here?
Yes _____
No _____ (Skip to Q1g)
1e. May I please speak to the other (FULL NAME)?
Yes _____ THANK INITIAL/INCORRECT RESPONDENT; WAIT TO RECORD “YES” WHEN
THE RESPONDENT IS READY TO BEGIN.

No _____
1f. Do you know a better time when we can reach the other (FULL NAME)?
________________________________________
RECORD INFORMATION ON AND BEST TIME TO REACH; THEN GO TO CLOSINGS.
1g. Do you know how we can reach the other (FULL NAME)?
________________________________________
RECORD INFORMATION ON HOW TO REACH (COLLECT PHONE AND BEST TIME TO
REACH); THEN GO TO CLOSINGS.
2a According to your birthdate that we have on record, you should be ^DSP_Respondent_Age years old.
Is this accurate?
YES _____ (Q3) NO _____
2b. What is your correct age?

______

IF <50 GO TO INELIGIBLE1
3. Do you have a blood clotting disorder such as hemophilia?
Yes _____ (GO TO INELIGIBLE2) No _____
4. Not including non-melanoma skin cancer, have you been diagnosed by a doctor with any type of
cancer in the last three years? [IF REG FOLLOW-UP VISIT SAY: Not including non-melanoma skin
cancer, have you been diagnosed by a doctor with any type of cancer since your last visit?]
Yes _____ No _____ (GO TO PER)
a. In what organ or part of the body did your cancer start? (If you are not sure of the answer,
please give me your best guess).
b. In what year were you first diagnosed by a doctor with this cancer?
ENTER EACH CANCER AND DATE OF DIAGNOSIS.
1st cancer _____________________________Date of diagnosis _____/______/______
MM

DD

YYYY

2nd cancer (if applicable)_________________ Date of diagnosis _____/______/_____
MM

DD

YYYY

Personal Information (PER):
1. How tall are you? [IF REG FOLLOW-UP VISIT, DO NOT ASK. ENTER DK.]
____________________feet / inches
2. How much do you weigh now? ____________________ pounds
3. In the last 7 days, have you used aspirin or aspirin-containing products, such as Bayer, Bufferin,
Anacin or Excedrin? (Please do not include aspirin-free products such as Tylenol and Panadol.)
Yes _____ No _____ (Q4)

2

a. What is the product name?: _______________
b. What is the product strength? Would you say:
Adult strength (usually 325mg), _____
Baby strength (usually 81mg), _____
Or some other strength? (SPECIFY) _____
c. How many pills of aspirin or aspirin-containing products have you taken in the last 7
days? ______
d. When did you last take aspirin or aspirin-containing products?
_____ days ago or _____ hours ago or _____ minutes ago
4. In the last 7 days, have you used ibuprofen-containing products, such as Advil, Nuprin, or Motrin?
Yes _____ No _____ (Q5)
a. What is the product name: _______________
b. How many pills of ibuprofen-containing products have you taken in the last 7 days?
____
c. When did you last take ibuprofen-containing products?
_____ days ago or _____ hours ago or_____ minutes ago
5. Are you regularly taking any blood thinning medications, such as Heparin, Coumadin, or plavix?
Since we have already asked you about aspirin, you do not need to report that here.
Yes _____ No _____ (Q7)
6. Which blood thinning medication(s) do you regularly take?
a. HEPARIN
b. COUMADIN
c. PLAVIX
d. OTHER (SPECIFY) ______________________________________________________
7. In the last 30 days, have you taken any prescribed medicines? [IF THIRD REG FOLLOW-UP
VISIT SAY: Since your last visit, have you taken any prescribed medicines]
Yes _____ No _____ (Q8)
a. Can you please tell me the name or names of the each prescription medication you are
taking? REFER TO BOTTLES ASSEMBLED BY PARTICIPANT. REVIEW
TOGETHER AND ENTER.
___________________________________________________________________________
Next, I’m going to ask you about different conditions with which you may have been diagnosed. Please
answer yes or no for each one.
[IF REG FOLLOW-UP VISIT SAY: I have to ask these questions the same way each time, so I may ask
you about something you already told me at a previous recent visit. Please bear with me.]
8. Has a doctor or other medical professional ever told you you had:
a.
b.
c.
d.
e.

Heart disease?
High blood pressure or hypertension?
Diabetes?
Rheumatoid arthritis?
An autoimmune disease? (IF ASKED: multiple sclerosis,

YES
1
1
1
1
1

NO
2
2
2
2
2

3

sarcoidosis, lupus, or Sjogren’s disease)
f. Hay fever, seasonal allergies or allergic rhinitis?
g. Eczema?
h. Asthma?

1
1
1

2
2
2

The next series of questions deals with conditions or symptoms that you may have had within the last 12
months. If you need to, please use the calendar to help with your answers.
9. During the last 12 months, have you had any symptoms of hay fever, seasonal allergies or allergic
rhinitis? Examples of symptoms include having a stuffy, itchy or runny nose or watery, itchy eyes.
Please do not include symptoms related to a cold or the flu.
Yes _____ No _____ (Q9g)
a. In the last 12 months, what allergy symptoms have you had? (select all that apply)
Stuffy, itchy or runny nose
Watery, itchy eyes
Sinusitis or sinus pain or pressure
Other symptoms:______________
b. Were the symptoms worse after working with grains or hay?
Yes _____
No _____
Did not work with grains or hay _____
c. Were the symptoms worse after working with animals?
Yes ____
No _____
Did not work with animals _____
d. On how many days did you have symptoms of allergies within the last 30 days?
_____ days [0-30]
e. On how many days did you have symptoms of allergies within the last 7 days?
_____ days [0-7]
f.

Have you had any symptoms of allergies yesterday or today?
Yes _____ No _____

g. Did you use any medications to treat or prevent allergy symptoms?
Yes _____ No _____ (Q10)
h. Please list the medications you used to treat your allergies.
Name of medication(s): __________

10. During the last 12 months, have you had any itching or other symptoms of eczema?
Yes _____ No _____ (Q10d)
a. Have you had symptoms of eczema in the last 30 days?
Yes _____ No _____ (Q10d)

4

b. Have you had symptoms of eczema in the last 7 days?
Yes _____ No _____ (Q10d)
c. Have you had symptoms of eczema yesterday or today?
Yes _____ No _____
d. Did you use any medications to treat eczema?
Yes _____ No _____ (Q11)
e. Please list the medications you used to treat your eczema: __________
11. During the last 12 months, have you had an episode of asthma or an asthma attack?
Yes _____ No _____ (Q11d)
a. Have you had any symptoms of asthma or an asthma attack in the last 30 days?
Yes _____ No _____ (Q11d)
b. Have you had any symptoms of an asthma or asthma attach in the last 7 days?
Yes _____ No _____ (Q11d)
c. Have you had any symptoms of asthma or asthma attack yesterday or today?
Yes _____ No _____
d. Did you use any medications for asthma or asthma attack?
Yes _____ No _____ (Q12)
e. Please list the medications you used to treat your asthma.
Name of medication(s): __________
The next series of questions deals with conditions that you may have had within the last 30 days. [IF
THIRD REG FOLLOW-UP VISIT SAY: The next series of questions deals with conditions that you may
have had since your last visit.] If you need to, please use the calendar to help with your answers.
12. In the last 30 days, have you had [IF REG FOLLOW-UP VISIT SAY: Since your last visit, have
you had]:
a. A Cold or flu? Yes _____ No _____ (Q12b)
When did symptoms begin? ______/_______/________
MM

DD

YYYY

When did symptoms resolve? _____/_______/________
MM

DD

YYYY

b. (In the last 30 days/Since your last visit, have you had) bronchitis or pneumonia?
Yes _____ No _____ (Q12c)
When did symptoms begin? ______/_______/________
MM

DD

YYYY

When did symptoms resolve? _____/_______/________
MM

DD

YYYY

c. (In the last 30 days/Since your last visit, have you had) sinusitis or sinus problems?
Yes _____ No _____ (Q12d)
When did symptoms begin? _____/_______/________

5

MM

DD

YYYY

When did symptoms resolve? _____/_______/________
MM

DD

YYYY

d. Have you had any other type of infection (in the last 30 days/since your last visit)?
Yes _____ No _____ (Q13)
List type(s)_______________________________________________________
When did symptoms begin? _____/_______/________
MM

DD

YYYY

When did symptoms resolve? _____/_______/________
MM

DD

YYYY

Now I’m going to ask about medical or dental x-rays or any other radiologic procedures you may have
had during the last 12 months. [IF REG FOLLOW-UP VISIT SAY: Now I’m going to ask about
medical or dental x-rays or any other radiologic procedures you may have had since your last visit.]
13. During the last 12 months/Since your last visit, have you had (any/a):
IF YES: When did you have the
Type of Procedure
[Type of Procedure]?
a) Medical x-rays?
(mm/dd/yyyy)
b) Dental x-rays?
(mm/dd/yyyy)
c) CT scan or CAT Scan?
(mm/dd/yyyy)
d) Fluoroscopy?
(mm/dd/yyyy)
e) PET scan?
(mm/dd/yyyy)
f) Diagnostic radioisotopes, for example a thallium stress test?
(mm/dd/yyyy)
g) Other type of radiologic procedure?
(mm/dd/yyyy)

14. How many servings of alcoholic beverages did you drink in the last seven days? A serving of an
alcoholic beverage is defined as 12 fluid ounces of beer, 5 fluid ounces of wine, and 1.5 fluid ounces
of hard liquor. Number of servings: __________
IF NUMBER OF SERVINGS = 0 (NONE), GO TO Q16_INTRO.
15. How many servings of alcoholic beverages did you drink in the last 24 hours? A serving of an
alcoholic beverage is defined as 12 fluid ounces of beer, 5 fluid ounces of wine, and 1.5 fluid ounces
of hard liquor. Number of servings: __________
The next series of questions deals with your tobacco use.
16.
Do you currently smoke cigarettes, a pipe, or cigars, or use other tobacco products such as
chewing tobacco or snuff?
Yes _____ No _____ (OAG)
17.

How often do you (smoke/use) [Product]? (Would you say every day, some days or not at all?)
Product
Every day
Some days
Not at all
Cigarettes
A pipe
Cigars
Cigarillos

6

Chewing tobacco
Snuff
Do you smoke or use any
other type of tobacco
products? (SPECIFY)
Other agricultural exposures section (OAG)
Now I would like to ask you a few questions about your activities at work and on your farm.
18. At what age did you first live on a farm?
_____ [0-99]
Enter 99 for never lived on a farm
19. In total, how many years did you spend living on a farm?
a. Before age 18:
b. Over your entire lifetime:
20. In the last 12 months, have you personally performed farm work or farming activities? [IF REG
FOLLOW-UP VISIT SAY: Since your last visit, have you personally performed farm work or
farming activities?]
Yes _____ No _____ (Q36)
21. Excluding gardens for personal use, what crops, including fruits and vegetables, were raised on your
farm in the last 12 months? [IF REG FOLLOW-UP VISIT SAY: Excluding gardens for personal use,
what crops, including fruits and vegetables, were raised on your farm since your last visit?]
None
Apples
Alfalfa
Barley
Bermuda grass
Blueberries
Cabbage
Christmas trees
Corn field

Corn pop
Corn seed
Corn sweet
Cotton
Cucumbers
Grapes
Hay or forage
Melons
Oats

Peaches
Peanuts
Peppers
Potatoes
Rye
Snap beans
Sorghum
Soybeans
Strawberries

Sweet potatoes
Tomatoes
Tobacco
Wheat
Nursery crops
Pumpkins
Other:
__________

If response in 21 = Cornfield, corn seed, oats, sorghum, soybeans, rye, barley, or wheat, ask questions
22 and 23.
If response in 21 = cotton then ask question 24 and 25.
If response in 21 = Alfalfa or Hay or Forage then go to question 26 and 27.
If Cornfield, corn seed, oats, sorghum, soybeans, rye, barley, wheat, cotton, alfalfa, hay, forage are
not selected in 21 skip to question 29.
22. Have you spent any time in the past 12 months harvesting grain/soybeans/corn field/corn seed?
Yes _____ No _____ (Q23)
a. How many days have you spent harvesting grain/soybeans/corn field/corn seed in the last
12 months?
None _____ (Q23)
1-7 Days _____

7

8-20 Days _____
21 or More Days _____
b. How many days have you spent harvesting grain/soybeans/corn field/corn seed in the last
30 days?
None _____ (Q23)
1-3 Days _____
4-7 Days _____
8 or More Days _____
c. How many days have you spent harvesting grain/soybeans/corn field/corn seed in the last 7
days?
None _____
1-3 Days _____
4-7 Days _____
d. Did you harvest grain/soybeans/corn field/corn seed yesterday or today?
Yes _____ No _____
23. Have you spent any time in the past 12 months hauling grain/soybeans/corn field/corn seed?
Yes _____ No _____ (Q24)
a. How many days have you spent hauling grain/soybeans/corn field/corn seed in the last 12
months?
None _____ (Q24)
1-7 Days _____
8-20 Days _____
21 or More Days _____
b. How many days have you spent hauling grain/soybeans/corn field/corn seed in the last 30
days?
None _____ (Q23e)
1-3 Days _____
4-7 Days _____
8 or More Days _____
c. How many days have you spent hauling grain/soybeans/corn field/corn seed in the last 7
days?
None _____
1-3 Days _____
4-7 Days _____
d. Did you haul grain/soybeans/corn field/corn seed yesterday or today?
i. Yes
ii. No
e. On days when you hauled grain/soybeans/corn field/corn seed how many hours per day did
you spend?
Less than 30 Minutes _____
30-60 Minutes _____
1-3 Hours _____

8

More than 3 hours _____
f.

When you hauled grain/soybeans/corn field/corn seed did you load the wagon/truck
yourself
Yes _____ No _____

24. Have you spent any time in the past 12 months harvesting cotton?
Yes _____ No _____ (Q25)
a. How many days have you spent harvesting cotton in the last 12 months?
None _____ (Q25)
1-7 Days _____
8-20 Days _____
21 or More Days _____
b. How many days have you spent harvesting cotton in the last 30 days?
None _____ (Q25)
1-3 Days _____
4-7 Days _____
8 or More Days _____
c. How many days have you spent harvesting cotton in the last 7 days?
None _____
1-3 Days _____
4-7 Days _____
d. Did you harvest cotton yesterday or today?
Yes _____ No _____
25. Have you spent any time in the past 12 months hauling cotton?
Yes _____ No _____ (Q26)
a. How many days have you spent hauling cotton in the last 12 months?
None _____ (Q26)
1-7 Days _____
8-20 Days _____
21 or More Days _____
b. How many days have you spent hauling cotton in the last 30 days?
None _____ (Q25e)
1-3 Days _____
4-7 Days _____
8 or More Days _____
c. How many days have you spent hauling cotton in the last 7 days?
None _____
1-3 Days _____
4-7 Days _____
d. Did you haul cotton yesterday or today?
Yes _____ No _____

9

e. On days when you hauled cotton how many hours per day did you spend?
Less than 30 Minutes _____
30-60 Minutes _____
1-3 Hours _____
More than 3 hours _____
f.

When you hauled cotton did you load the wagon/truck yourself
Yes _____ No _____

26. Have you spent any time in the past 12 months baling alfalfa or hay?
Yes _____ No _____ (Q27)
a. How many days have you spent baling alfalfa or hay in the last 12 months?
None _____ (Q27)
1-7 Days _____
8-20 Days _____
21 or More Days _____
b. How many days have you spent baling alfalfa or hay in the last 30 days?
None _____ (Q26e)
1-3 Days _____
4-7 Days _____
8 or More Days _____

c. How many days have you spent baling alfalfa or hay in the last 7 days?
None _____
1-3 Days _____
4-7 Days _____
d. Did you bale alfalfa or hay yesterday or today?
Yes _____ No _____
e. When you baled alfalfa or hay, do you usually make large (round) bales or small (square or
rectangular) bales?
Large, Round or_____
Small, Square/Rectangular or _____
Both Equally _____
27. Have you spent any time in the past 12 months hauling alfalfa or hay?
Yes _____ No _____ (Q28)
a. How many days have you spent hauling alfalfa or hay in the last 12 months?
None _____ (Q28)
1-7 Days _____
8-20 Days _____
21 or More Days _____
b. How many days have you spent hauling alfalfa or hay in the last 30 days?
None _____ (Q27e)

10

1-3 Days _____
4-7 Days _____
8 or More Days _____

c. How many days have you spent hauling alfalfa or hay in the last 7 days?
None _____
1-3 Days _____
4-7 Days _____
d. Di you haul alfalfa or hay yesterday or today?
Yes _____ No _____
e. On days when you hauled alfalfa or hay how many hours per day did you spend?
Less than 30 Minutes _____
30-60 Minutes _____
1-3 Hours _____
More than 3 hours _____
f.

When you hauled alfalfa or hay did you load the wagon/truck yourself
Yes _____ No _____

Now we are going to ask you about livestock, poultry, or other animals you may have raised on your
farm.
28. In the last 12 months, have you raised poultry, livestock, or other animals for income on your farm?
[IF REG FOLLOW-UP VISIT SAY: Since your last visit, have you raised poultry, livestock, or other
animals for income on your farm?]
Yes _____ No _____ (Q35)
29. How many [Type] were raised for income on your farm?
TYPE
NUMBER
Beef cattle
Dairy cattle
Hog/swine
Poultry
Poultry for eggs
Sheep or goats
Horses
Other animals (SPECIFY)
30. Have you mixed feed with antibiotics in the past 12 months?
Yes _____ No _____ (Q33)

31. Have you mixed feed with antibiotics in the past 30 days?
Yes _____ No _____ (Q33)
32. Have you mixed feed with antibiotics in the past 7 days?
Yes _____ No _____

11

33. (IF YES TO RAISING POULTRY OR POULTRY FOR EGGS) Have you spent time in a poultry
confinement area within the last 30 days? [IF THIRD REG FOLLOW-UP VISIT SAY: Have you
spent time in a poultry confinement area since your last visit?]
Yes___
No____ (Q34)
If Yes, How much time did you spend in the poultry confinement area?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? None, <30 min, 30-60 min, 1-2 hours, > 2 hours
If Yes, How much time did you spend cleaning the poultry confinement area?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? None, <30 min, 30-60 min, 1-2 hours, > 2 hours
If Yes, How much time did you spend mixing poultry feed and feeding poultry?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? None, <30 min, 30-60 min, 1-3 hours, > 3 hours
34. (IF YES TO SWINE) Have you spent time in swine confinement area within the last 30 days? [IF
THIRD REG FOLLOW-UP VISIT SAY: Have you spent time in a swine confinement area since
your last visit?]
Yes___
No___ (Q35)
If Yes, How much time did you spend in the swine confinement area?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? None, <30 min, 30-60 min, 1-2 hours, > 2 hours
If Yes, How much time did you spend cleaning the swine confinement area?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? None, <30 min, 30-60 min, 1-2 hours, > 2 hours
If Yes, How much time did you spend mixing swine feed and feeding swine?
In the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40 hours
In the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
Yesterday or today? – None, <30 min, 30-60 min, 1-3 hours, > 3 hours
35. In the last month, how many times have you performed the following activities? [IF THIRD REG
FOLLOW-UP VISIT SAY: Since your last visit, how many times have you performed the following
activities?]
Activity
Responses
35a. How often have you worked with or around
Not at all (Q35b)
stored seed or grain on your farm or elsewhere
1-3 times
(such as grain elevators or feed mills)?
4-20 times
aa. If >Not at all, How many times have you
>20 times
worked with or around stored seed or grain in
the last 7 days? Not at all, 1-3 times, 3-7 times,
>7 times
bb. If > Not at all in prev. 7 days, Did you work
with or around stored seed or grain yesterday?
Yes No

12

cc. If >Not at all to aa, Each time you did this, on
average how long did you spend working with
or around stored seed or grain? <10 min; 10-30
min, 30 min-1hr, >1 hr
35b. How often have you ground animal feed?
Would you say (READ RESPONSES):
aa. If >Not at all, How many times have you
ground animal feed in the last 7 days? Not at
all, 1-3 times, 3-7 times, >7 times
bb. If > Not at all in prev. 7 days, Did you grind
animal feed yesterday or today? Yes No
cc. If >Not at all to aa, Each time you did this, on
average how long did you spend grinding
animal feed? <10 min; 10-30 min, 30min-1hr,
>1 hour

Not at all (Q35c)
1-3 times
4-20 times
>20 times

35c. (How about) cleaning grain bins?
aa. If >Not at all, How many times have you
cleaned grain bins in the last 7 days? Not at all,
1-3 times, 3-7 times, >7 times
bb. If > Not at all in prev. 7 days, Did you clean
grain bins yesterday or today? Yes No
cc. If >Not at all to aa, Each time you did this, on
average how long did you spend cleaning grain
bins? Not at all, <10 min; 10-30 min, 30min1hr, >1 hour

Not at all (Q35d)
1-3 times
4-20 times
>20 times

35d. (How about) working with or around moldy
hay or straw?
aa. If >Not at all, How many times have you
worked with or around moldy hay or straw in
the last 7 days? Not at all, 1-3 times, 3-7 times,
>7 times
bb. If > Not at all in prev. 7 days, Did you work
with or around moldy hay or straw yesterday or
today? Yes No
cc. If >Not at all to aa, each time you did this, on
average how long did you spend working with
or around moldy hay or straw? <10 min; 10-30
min, 30min-1hr, >1 hour

Not at all (Q35e)
1-3 times
4-20 times
>20 times

35e. How about milking cows or other animals?
Would you say:
aa. If >Not at all, How many times have you
milked cows or other animals in the last 7
days? Not at all, 1-3 times, 3-7 times, >7 times
bb. If > Not at all in prev. 7 days, Did you milk
cows or other animals yesterday or today? Yes
No
cc. If >Not at all to aa, Each time you did this, on

Not at all (Q35f)
1-3 times
4-20 times
>20 times

13

average how long did you spend milking cows
or other animals? <30 min; 30-60 min, 1-3
hours, >3 hour
35f. (How about) cleaning barns, animal
confinements or replacing animal bedding in other
indoor facilities?
aa. If >Not at all, How many times have you
cleaned barns or other animal facilities in the
last 7 days? Not at all, 1-3 times, 3-7 times, >7
times
bb. If > Not at all in prev. 7 days, Did you work
clean barns or other animal facilities yesterday
or today? Yes No
cc. If >Not at all in aa, Each time you did this, on
average how long did you spend cleaning barns
or other animal facilities? <10 min; 10-30 min,
30min-1hr, >1 hour

Not at all (Q36 Intro)
1-3 times
4-20 times
>20 times

[IF REG FOLLOW-UP VISIT, ASK IF THERE HAS BEEN ANY CHANGE IN THE NUMBER OF
NON-INCOME GENERATING ANIMALS ON PT FARM, SUCH AS SUCH AS DOGS, CATS, OR
HORSES. IF PT SAYS YES, THEN ASK Q36. IF PT SAYS NO, ENTER DK.]
36. Are there currently any (other) non-income generating animals on your farm, such as dogs, cats, or
horses?
Yes _____ No _____ (Q38)
37. How many [Type] are (in your home/on your farm)?
Type
NUMBER:
Dogs
Cats
Horses
Other animals (SPECIFY)
Poultry
Poultry for eggs
38. In the last 12 months, have you worked around wood dust, such as at a saw mill, in furniture-making,
or other wood-working activities? Yes _____ No _____
a. If Yes, How many hours in the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40
hours
b. If >0, How many hours in the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours
c. If >0 How many hours yesterday or today? None, <30 min, 30-60 min, 1-3 hours, > 3 hours
39. In the last 12 months, have you performed veterinarian services on animals on your farm or for other
farmers? Yes _____ No _____
a. If Yes, How many hours in the past 30 days? None, <= 7 hours, >7-20 hours, >20-40 hours, >40
hours
b. If >0, How many hours in the past 7 days? None, <= 7 hours, >7-20 hours, > 20 hours

14

c. If >0 How many hours yesterday or today? None, <30 min, 30-60 min, 1-3 hours, > 3 hours
40. In the last 7 days, have you done any welding? Yes _____ No _____
41. In the last 7 days, have you done any painting, varnishing, or staining? Yes _____ No _____
42. In the last 7 days, have you repaired engines? Yes _____ No _____
[IF REG FOLLOW-UP VISIT, ASK IF PT HAS GOTTEN A NEW JOB OTHER THAN WORKING
ON FARM SINCE LAST VISIT. IF PT SAYS YES, THEN ASK Q43. IF PT SAYS NO, ENTER DK.]
43. Do you currently have a job other than working on a farm?
Yes _____ No _____ (GO TO Occupation Intro)
a. What is your current job other than farming? ______________________________
b. What type of business is this job in? Would you say:
Manufacturing?
A retail store?
Wholesale or distributor?
A service provider?
Construction?
Mining?
Farming, fishing, or forestry?
Government or military?
A shipyard?
Or some other type of business (SPECIFY)? ______________________________
c. How long have you had this job? _______________ months / years
d. Is this job year round or seasonal?
Year round _____ Seasonal _____
Occupation Information (OCC)
I would now like to ask about your use of pesticides in the last 12 months. [IF REG FOLLOW-UP VISIT
SAY: I would now like to ask about your use of pesticides since your last visit.] This includes the use of
herbicides, insecticides, fungicides, fumigants, or other chemicals used to kill plants, insects, fungi,
molds, or rodents. Please do not include the use of antibiotics, sanitizers, antimicrobial soaps or
fertilizers.
1. In the last 12 months/Since your last visit, have you personally mixed, loaded, handled or applied
these chemicals for use on crops, animals, or any other purpose NOT including home and garden use?
We will ask you separately about the use of pesticides in your home and garden.
Yes _____ No _____ (Go to HOM)
2. Which products have you used (in the last 12 months/since your last visit)? Please give the product
trade name, if possible:
_________________________________________________________________________________
[IF SHOWCARD IS COMPLETED, REVIEW WITH PARTICIPANT AS YOU ENTER DATA;

15

IF SHOWCARD IS NOT COMPLETED, PROBE FOR PRODUCT NAMES ONLY.]
IF OTHER: Please give the product trade name, if possible. __________________
IF OTHER: If label is available, what is the active ingredient in [OTHER]? __________________
IF OTHER: What is the EPA Registration number for [OTHER]? _________________

3. In the last 12 months, on how many days did you mix, load or apply [insert pesticide name]? [IF REG
FOLLOW-UP VISIT SAY: Since your last visit, on how many days did you mix, load or apply [insert
pesticide name].]
Total number of days: __________
Don’t know
4. I would like to ask you about the dates of the three most recent uses of [insert pesticide name] (within
the last 12 months/since your last visit) and the amount of time that you spent mixing, loading or applying
[insert pesticide name] on each date.
(What is the most/What was the next most) recent date you mixed, loaded or applied [insert pesticide
name]? (The time before [Date]).
Date
How many hours did you spend mixing, loading, or applying [insert pesticide
name] on [Date]?
1 (mm/dd/yy)
2 (mm/dd/yy)
3 (mm/dd/yy)
5. In the last 12 months/Since your last visit, did you personally mix and/or load [insert pesticide name]?
Yes _____ No _____ (Q6)
a. Was the [insert pesticide name] that you mixed and/or loaded a:
Liquid,
Powder,
Granule,
Dissolvable packet,
Or something else? OTHER: SPECIFY ____________________
b. When you mixed and/or loaded [insert pesticide name] did you normally wear gloves?
Yes _____ No _____ (Q5e)
c. What type of glove did you normally wear when you mixed and/or loaded [insert pesticide
name]? Was it a:
Chemical resistant glove like nitrile?
Rubber or plastic waterproof glove?
Thin disposable glove like latex?
Fabric or leather?
Another type of glove? (SPECIFY): __________

16

d. What (other) personal protective equipment did you normally wear when mixing and/or
loading [insert pesticide name]? Did you wear:
NONE
Goggles?
Face shield?
Disposable coveralls, like Tyvek?
Chemical-resistant jacket and pants?
Chemical-resistant apron?
Rubber boots?
Respirator? Which type? (SPECIFY) __________________
Dust mask?
Long-sleeved shirt?
Something else? OTHER: SPECIFY________________

6. In the last 12 months/Since your last visit, did you personally apply [insert pesticide name]?
Yes _____ No _____ (Next pesticide; else skip to Home and Garden Pesticide Use Questions)
a. Was [insert pesticide name] applied to:
Crop(s)? To which crops was it applied? (SPECIFY) _______________
Animals or animal confinement areas?
Anything else? OTHER (SPECIFY): _______________
b. Was [insert pesticide name] applied as a liquid, powder, granule or something else?
LIQUID
POWDER
GRANULE
SOMETHING ELSE: SPECIFY _______________
c. What application method(s) was used? Was it:
Broadcast or boom spray?
Hand spray?
Air blast?
Or something else? OTHER (SPECIFY)_________________
d. When you mixed and/or loaded [insert pesticide name] did you normally wear gloves?
Yes _____ No _____ (Q6f)
e. What type of glove did you normally wear when you applied [insert pesticide name]? Was it
a:
Chemical resistant glove like nitrile?
Rubber or plastic waterproof glove?
Thin disposable glove like latex?
Fabric or leather?
Another type of glove? (SPECIFY): __________
f.

What (other) personal protective equipment did you normally wear when applying [insert
pesticide name]? Did you wear:
NONE
Goggles?

17

Face shield?
Disposable coveralls, like Tyvek?
Chemical-resistant jacket and pants?
Chemical-resistant apron?
Rubber boots?
Respirator? Which type? (SPECIFY) __________________
Dust mask?
Long-sleeved shirt?
Something else? OTHER: SPECIFY________________
Home and Garden Pesticide Use Questions (HOM)
I would now like to ask about your use of pesticides in your home and garden in the last 12 months. This
includes the use of herbicides, insecticides, fungicides, fumigants, or other chemicals used to kill plants,
insects, fungi, molds, or rodents. Please do not include the use of antibiotics, sanitizers, antimicrobial
soaps or fertilizers.
1. In the last 12 months/Since your last visit, have you personally used pesticides in your home and
garden?
Yes _____ No _____ (END)

2. Which products have you used in your home and garden (in the last 12 months/since your last visit)?
Please give the product trade name, if possible:
_________________________________________________________________
[IF SHOWCARD IS COMPLETED, REVIEW WITH PARTICIPANT AS YOU ENTER DATA;
IF SHOWCARD IS NOT COMPLETED, PROBE FOR PRODUCT NAMES ONLY.]
IF OTHER: Please give the product trade name, if possible. __________________
IF OTHER: If label is available, what is the active ingredient in [OTHER]? __________________
IF OTHER: What is the EPA Registration number for [OTHER]? _________________

Closings
COMPLETE INTERVIEW
This concludes the interview portion of the visit. I appreciate your taking the time with me to answer
these questions. Now I am going to get set up for the blood draw.
Interviewer Remarks
R1.

PARTICIPANT’S COOPERATION WAS:
1. VERY GOOD
2. GOOD
3. FAIR
4. POOR

18

R2.

THE OVERALL QUALITY OF THIS INTERVIEW IS:
1. HIGH QUALITY
2. GENERALLY RELIABLE
3. QUESTIONABLE
4. UNSATISFACTORY

NO INTERVIEW1
Ok, then. Thank you very much.
NO INTERVIEW2
I’m sorry for the confusion. That is all the questions I have for you at this time. Thank you for speaking
with me today.
NO INTERVIEW3
That is all the questions I have for you at this time. Thank you for speaking with me today.
INELIGIBLE 1: I apologize. Our records indicated that you were within the age range we are including
in the study. However, based on this updated information on your age, you are not eligible for this part of
the Agricultural Health Study. Thank you for your time today.
INELIGIBLE 2: Unfortunately, you are not eligible for this part of the Agricultural Health Study: we
are looking for a group of men who are able to provide blood samples. Thank you for your time today

19