Form 20 Attachment 19-2 BEEA CAPI Questionnaire Controls

Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
Biological Sample Collection Questionnaire - Controls
Agricultural Health Study
Location of Residence (County, State): ___________________
Date: _____/______/______
MM

DD

YYYY

OMB #: 0925-0406
Expiration date: 09/30/2016
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 WORK HISTORY 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)?
________________________________________

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants

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?
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?
____________________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)
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) _____

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
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?
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.

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,
sarcoidosis, lupus, or Sjogren’s disease)

YES
1
1
1
1
1

NO
2
2
2
2
2

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
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 _____ (Q9.a) No _____ (Q10)
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. On how many days did you have symptoms of allergies within the last 30 days?
_____ days [0-30]
c. On how many days did you have symptoms of allergies within the last 7 days?
_____ days [0-7]
d. Have you had any symptoms of allergies yesterday or today?
Yes _____ No _____
e. Did you use any medications to treat or prevent allergy symptoms?
Yes _____ No _____ (Q10)
f.

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 _____ (Q10.a) No _____ (Q11)
a. Have you had symptoms of eczema in the last 30 days?
Yes _____ (Q10.b) No _____ (Q10.d)
b. Have you had symptoms of eczema in the last 7 days?
Yes _____ (Q10.c) No _____ (Q10.d)
c. Have you had symptoms of eczema yesterday or today?
Yes _____ (Q10.d) No _____ (Q10.d)
d. Did you use any medications to treat eczema?
Yes _____ (Q10.e) 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 _____ (Q11.a) No _____ (Q12)

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
a. Have you had any symptoms of asthma or an asthma attack in the last 30 days?
Yes _____ (Q11.b) No _____ (Q11.d)
b. Have you had any symptoms of an asthma or asthma attach in the last 7 days?
Yes _____ (Q11.c) No _____ (Q11.d)
c. Have you had any symptoms of asthma or asthma attack yesterday or today?
Yes _____ (Q11.d) No _____ (Q11.d)
d. Did you use any medications for asthma or asthma attack?
Yes _____ (Q11.e) 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 you
need to, please use the calendar to help with your answers.
12. In the last 30 days, 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, 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, have you had) sinusitis or sinus problems?
Yes _____ No _____ (Q12d)
When did symptoms begin? _____/_______/________
MM

DD

YYYY

When did symptoms resolve? _____/_______/________
MM

DD

YYYY

d. Have you had any other type of infection (in the last 30 days)?
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.

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
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
Chewing tobacco
Snuff
Do you smoke or use any
other type of tobacco
products? (SPECIFY)

Other agricultural exposures section (OAG)
Next I want to ask you a few questions about whether you have ever lived on a farm or performed farm
work.
1. Have you ever lived on a farm?
Yes _____ No _____ (go to OCC)

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
2. At what age did you first live on a farm?
_____ [0-99]
3. In total, how many years did you spend living on a farm?
a. Before age 18:
b. Over your entire lifetime:
4. Since the age of 18, have you personally performed farm work or farming activities?
Yes _____ No _____ (HOM)
5. When did you last perform farm work or farming activities?
___/___/______ OR ____ YEARS AGO
MM DD

YYYY

Home and Garden Pesticide Use Questions (HOM)
I would now like to ask about your use of pesticides around 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, have you personally used pesticides in your home and garden?
Yes _____ No _____ (GO TO Q3.)
2. Which products have you used in your home and garden in the last 12 months? Please give the
product trade name, if possible:
_________________________________________________________________

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. Do you or does anyone in your household have any pets or other animals, such as dogs, cats, or horses?
Yes _____ No _____ (OCC)
4. How many [Type] do you have?
Type
Dogs
Cats
Horses
Poultry
Poultry for eggs
Other animals (SPECIFY)

NUMBER:

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
Occupation Information (OCC)

In this next section, I am going to ask you about the kind of work you have done since you were at least
18 years old. Before I do that, I’d like to review the Work History Calendar you completed. REVIEW
THE JOB AND COMPANY COLUMNS OF THE WORK HISTORY CALENDAR WITH THE
PARTICIPANT. IF THE CALENDAR HAS NOT BEEN COMPLETED, ASK PARTICIPANT TO
COMPLETE IT BEFORE CONTINUING.

1. Have you held any part-time jobs for a total of at least 12 months that you have not reported on this
calendar already? For example, please count a 3-month part-time job that you held for 4 years.
Include only jobs you’ve held when you were at least 18 years old.
Yes _____ No _____
ADD ADDITIONAL JOBS TO CALENDAR. DETERMINE WHICH JOBS WERE HELD FOR >= 12
MONTHS AND PLACE A CHECK MARK NEXT TO THEM ON THE CALENDAR. THESE JOBS
QUALIFY TO BE ENTERED IN CAPI.
2. [INTERVIEWER: HOW MANY JOBS QUALIFY?]
NONE _____ (CLOSINGS)
ONE _____
TWO OR MORE _____

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
ENTER THE START YEAR, JOB TITLE, EMPLOYER NAME AND STOP YEAR FOR EACH JOB
LISTED ON THE WORK HISTORY CALENDAR WITH A CHECK MARK NEXT TO IT.
IF ASKING ABOUT SAME
EMPLOYER FOR > 1 JOB,
VERIFY OC-3 AND OC-4.
OC-3.
What type of business {is/was}
this? [INTERVIEWER: SELECT
ALL THAT APPLY.]

MANUFACTURING ................
A RETAIL STORE ....................
WHOLESALE OR
DISTRIBUTOR .........................
A SERVICE PROVIDER ..........
CONSTRUCTION .....................
MINING.....................................
FARMING, FISHING, OR
FORESTRY ...............................
GOVERNMENT OR
MILITARY ................................
A SHIPYARD............................
SOME OTHER TYPE OF
BUSINESS (SPECIFY) .............

10
11
12
13
14
15

OC-4.
What did {Employer
Name} make, or what
service did they provide?

OC-4a.
On average
how many
days per
week did
you work
on this job?

OC-5.
How many
months per
year did
you usually
work on
this job?

OC-6.
About how
many hours
per week
did you
usually
work on
this job?

|___|
DAYS
PER
WEEK

|___|___|
MONTHS
PER YEAR

|___|___|
HOURS
PER
WEEK

16
17
18
91

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
IF START YEAR <> DK OR RF AND STOP YEAR <> DK OR RF, GO TO OC-7. OTHERWISE,

CONTINUE WITH OC-6a.

OC-6a
Did you work at this job:

OC-7.
What were your main
activities or duties at this
job?

OC-8.
What kinds of chemicals
or materials, if any, did
you handle? Do not
include standard office
materials. TYPE “none”
IF NO CHEMICALS
WERE HANDLED.

OC-9.
What kinds of tools and
equipment, if any, did
you use? Do not include
computers or standard
office equipment. TYPE
“none” IF NO
EQUIPMENT WAS
USED.

Less than 5 years ......... 1
5 to 10 years, or........... 2
More than 10 years...... 3

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Attachment 19-2: BEEA Home Visit CAPI Instrument for Control Participants
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

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 study.
Thank you for your time today.
INELIGIBLE 2: Unfortunately, you are not eligible for this study: we are looking for a group of men
who are able to provide blood samples. Thank you for your time today

11