Draft - Introductory Survey Sample

Attachment 5 Lyme & Other Tickborne Diseases Prevention Study Knowledge, Attitudes, and Practices Introductory Survey
Interview Date: Interviewer’s Initials: Household ID #:
HOUSEHOLD INFORMATION
The next step in this study will be to take a short introductory survey about your yard, your recreational activities in your yard, and ticks. We will ask your permission to complete the introductory survey questions now. This survey should take no more than 10 minutes to complete. You will not receive a direct benefit from being part of this survey. Helping to carry out this research has a chance to tell us a lot about how to prevent tickborne diseases. This could be of future benefit to you or someone you know. There are no costs for participating in this survey. As compensation for your time and effort, you will receive a $X gift card in the mail along with the study forms. Before we begin I would like to remind you that participation in this survey is voluntary and you may refuse to answer any questions and may stop at any time. I would like to begin by asking some general questions about you.
How long has your family lived at this address? _________ Years _________ Months
Last summer, did you find any ticks crawling on or attached to you after spending time in your yard?					(1) Yes (2) No (3) Not applicable (didn’t live there last year) (4) Don’t know/Not sure (5) Refused
I would now like to ask you about the members of your household. Who lives in your home?
Family ID (LTDPS #-Family #)	Relationship to interviewee and initials (must include self)	Date of birth (mm/dd/yyyy)	Sex	Have/has [you or a household member] ever been diagnosed by a physician as having Lyme disease, babesiosis, anaplasmosis or ehrlichiosis? Any other tickborne disease?			When was the most recent onset of [Disease]? (month/year)	Are [you/he/she] currently being treated for this illness?
a.	Self (Initials)		 M  F	 No
				 Yes, Lyme disease				 Yes  No
				 Yes, Babesiosis				 Yes  No
				 Yes, Anaplasmosis/Ehrlichiosis				 Yes  No
				 Other, please specify _______________________				 Yes  No
				 Don’t know/Not sure
				 Refused
b.	Etc.		 M  F	 No
				 Yes, Lyme disease				 Yes  No
				 Yes, Babesiosis				 Yes  No
				 Yes, Anaplasmosis/Ehrlichiosis				 Yes  No
				 Other, please specify _______________________				 Yes  No
				 Don’t know/Not sure
				 Refused
c.	Etc.		 M  F	 No
				 Yes, Lyme disease				 Yes  No
				 Yes, Babesiosis				 Yes  No
				 Yes, Anaplasmosis/Ehrlichiosis				 Yes  No
				 Other, please specify _______________________				 Yes  No
				 Don’t know/Not sure
				 Refused
GENERAL PROPERTY CHARACTERISTICS
Now I would like to ask you some questions about your house and property.
Do you live in a home or housing development that was built more than 10 years ago?						 Yes  No  Don’t know/Not sure  Refused
What is the size of the lot on which your current home is located?						 1 acre or less  > 1 acre but less than 2 acres  2-2.9 acres  3-3.9 acres  4 acres or more  Don’t know/Not sure  Refused
How much of your property is composed of woods or forested areas?						 None of it  Less than half of it  About half of it  Greater than half of it  All of it  Don’t Know/Not Sure  Refused
How much of your property is lawn? [Lawn is a maintained grassy area]						 No lawn on property  Less than half of it  About half of it  Greater than half of it  All of it  Don’t Know/Not Sure  Refused
Does your property include woody or brushy areas?						 Yes  No  Don’t know/Not sure  Refused
LANDSCAPE CHARACTERISTICS
On average, how frequently is your lawn mowed during the spring and summer months? [Between the months of May and September]						 Less than once per month  Once to three times per month  Weekly  More often than weekly  Don’t Know/Not Sure  Refused

Who mows your lawn?	 Household member  Non-household member  Professional lawn care service  Other [specify] ____________________  Don’t Know/Not Sure  Refused
Do you have a vegetable garden in your yard?	 Yes  No  Don’t Know/Not Sure  Refused
Do you have a flower garden in your yard?	 Yes  No  Don’t Know/Not Sure  Refused
Do you have a compost pile?	 Yes  No  Don’t Know/Not Sure  Refused
Do you have a log pile in your yard?	 Yes  No  Don’t Know/Not Sure  Refused
Do you have a bird feeder in your yard for seed-eating birds?	 Yes  No  Don’t Know/Not Sure  Refused
Does your yard have fencing around it or parts of it?	 Yes  No  Don’t Know/Not Sure  Refused
Do you have one or more stone walls, not sealed by mortar or cement, in your yard or adjacent property line?	 Yes  No  Don’t Know/Not Sure  Refused
What type of recreational areas do you have in your yard that are not located on a deck or patio?
Children’s recreational equipment (e.g. jungle gym, swing set, sandbox, etc.)?	 Yes  No  Don’t Know/Not Sure  Refused
Dining area (e.g. picnic table, etc.)?	 Yes  No  Don’t Know/Not Sure  Refused
Sitting area (e.g. bench, hammock, etc.)?	 Yes  No  Don’t Know/Not Sure  Refused
Lawn sport area (e.g. horseshoe pit, volleyball, badminton, bocce, etc.)?	 Yes  No  Don’t Know/Not Sure  Refused
Other?

PERSONAL PROTECTION
I would like to ask you some questions about time spent in your yard and outdoors during the spring and summer months. For the purpose of this study, your yard is defined as all of the land on your property, not including your house, driveway, deck, porch, patio, garage, or other buildings on the property. For example, your yard may include a lawn, woods, and a garden.
Approximately how many hours per week do you spend in your yard?	 < 1 hour  1 – 5 hours  6 – 10 hours  >10 hours  Don’t know/Not sure  Refused
When spending time in your yard, where do you spend most of your time?	 Outdoor dining area (i.e., non-grassy area: patio/deck)  Lawn  Woody or brushy areas  Other
Approximately how many hours per week do you spend doing outdoor activities not on your property?	 < 1 hour  1 – 5 hours  6 – 10 hours  >10 hours  Don’t know/Not sure  Refused
In the last year, have any of your family members found ticks on their bodies?	 Yes (If yes to Q2 or Q22, go to Q23)  No (Go to Q24)  Don’t know/Not sure (Go to Q24)  Refused (Go to Q24)
Overall, how many tick bites did you and each of your family members have last year? (household total)	__________________  Don’t know/Not sure  Refused
How often do you use insect repellent when spending time in your own yard?	 All the time  More than half the time  About half the time  Less than half the time  Never  Don’t know/Not sure  Refused
How often do you use insect repellent when spending time outside of your yard?	 All the time  More than half the time  About half the time  Less than half the time  Never  Don’t know/Not sure  Refused
Does your insect repellent contain DEET?	 Yes  No  Don’t know/Not sure  Refused  My family does not use insect repellent
Does your insect repellent contain picaridin?	 Yes  No  Don’t know/Not sure  Refused  My family does not use insect repellent

Does your insect repellent contain IR3535?		 Yes  No  Don’t know/Not sure  Refused  My family does not use insect repellent
PETS
Do you have house pets that spend time both indoors and outside in your yard?		 Yes  No (if no pets, skip to ‘other’)  Don’t Know/Not Sure  Refused
Do you have a dog?		 Yes  No  Don’t know/Not sure  Refused
If yes, do you use tick control on your dog?		 Yes  No  Don’t know/Not sure  Refused
Do you have a cat?		 Yes  No  Don’t know/Not sure  Refused
If yes, do you use tick control on your cat?		 Yes  No  Don’t know/Not sure  Refused
OTHER
What is the highest grade or year of school you completed?	 Never attended school or kindergarten  Elementary or middle school; 1st – 8th grade  Some high school; 9th – 11th grade  High school graduate; 12th grade or GED  College or technical school for 1-3 years  College for 4 years, with or without a degree  Graduate school  Don’t know/Not sure  Refused
Are you of Hispanic, Latino, or Spanish origin?	 Yes  No  Don’t know/Not sure  Refused
What is your race? (check all that apply)	 American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White  Other, please specify____________________  Don’t know/Not sure  Refused
In your home, what is the annual household income from all sources, including social security and pensions? (read ranges)	 less than $15,000  less than $25,000  less than $35,000  less than $50,000  less than $70,000  $70,000 or more  Don’t know/Not sure  Refused
How did you learn about the study? Could you please provide/confirm your home address? Do you have pets that go outdoors? What is your preferred method of contact and the best day/time to reach you?

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