Form 10-10066 AHOBPR Questionnaire - Qarmat Ali Sub-population Follow-

Airborne Hazards
And Open Burn Pit Registry
Sub-Population Follow up
Questionnaire
(Qarmat Ali)
OMB 2900- ##XX
VA Form 10-10066

This information is collected in accordance with section 3507 of the Paperwork Reduction Act
of 1995. Accordingly, VA may not conduct or sponsor and you are not required to respond to a
collection of information unless it displays a valid OMB number. W e anticipate that the time
expended by all individuals who complete this questionnaire will average 40 minutes. This includes
the time it will take to read instructions, gather the necessary facts and fill out the form. The results of
this questionnaire will lead to improvement in the quality of service delivery by helping to shape the
direction and focus of specific programs and services. Submission of this form is voluntary and
failure to respond will have no impact on benefits to which you may be entitled.

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Airborne Hazards and Open Burn Pit
Registry Sub-Population Self-Assessment
Sub-Population Questionnaire: Qarmat Ali
Contents

Questions 1- 41
1. How many days between 01 April and 30 September 2002 were you physically
present at the Qarmat Ali Water Treatment Plant?
1-10
11-20
21-40
41+
I do not wish to Answer
I don’t know
2. Were you involved in activities that disrupted the soil or raised dust?
Yes
No
3. Did you experience sand storms while you were in Qarmat Ali?
Yes
No
4. Did you come in contact with dust on your skin?
Yes
No
5. Did you see red, yellow, or orange dust, on the ground or in the air, while you
were in Qarmat Ali?
Yes
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No
6. Did you inhale the dust while you were in Qarmat Ali?
Yes
No
7. Did you ingest the dust in your food, water or other Drinks?
Yes
No
8. Did you experience any of the following symptoms during your time at Qarmat
Ali or within two weeks after your service assignment at Qarmat Ali ended?
Inflammation of nasal passages
Development of a nasal septum perforation
Eye irritation
Skin rashes
Sores
I do not wish to answer
Don't Know
9. How would you rate your health during the past four weeks?
Excellent
Very Good
Good
Fair
Poor
Very Poor
10. Have you participated in any other Qarmat Ali exposure follow-up
assessments?
Yes
No
I do not wish to answer
I do not know
11.

Have you had a recent change in weight?
Yes
No
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12. How many workdays or days of your usual activities did you lose, due to
illness in the past 90 days? Please select an answer.
1-5
6-10
10 or more
13. Have you experienced a change in the frequency or pattern of headaches?
Yes
No
14. Do you have frequent (more than once a month) nosebleeds?
Yes
No
15. Frequent (more than once a month) hoarseness?
Yes
No
16. Frequent (more than once a month) colds?
Yes
No
17. Experiencing any other head, nose or throat symptoms?
Yes
No
18.

Coughing up blood?
Yes
No

19.

Chronic (daily) cough?
Yes
No

20.

Wheezing?
Yes
No
21. Shortness of breath?
Yes
No
22. Chest Pain?
Yes
No
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23.

Mucous or phlegm?
Yes
No

24.

Frequent (more than once a month) heartburn?
Yes
No

25. Skin symptoms?
Yes
No
26. Sinus Problems?
Yes
No
27. Do you have Chronic Obstructive Pulmonary Disease (COPD) which
includes chronic bronchitis and/or emphysema?
Yes
No
28. Have you been diagnosed with Pulmonary fibrosis?
Yes
No
29. Do you have Asthma?
Yes
No
30. Have you been diagnosed with lung cancer?
Yes
No
31. Have you been diagnosed with cancer other than lung cancer?
Yes
No
32.

List name/names/types of Non-lung Cancer diagnosis:

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33.

Have you smoked at least 100 cigarettes in your entire Life

Yes
No
34. How old were you when your first started smoking tobacco cigarettes?
12-15
16-20
21-25
26-30
31-35
36-40
41-45
41-50
51-55
56-60
61+
35. How old were you when you last quit smoking tobacco cigarettes?
12-15
16-20
21-25
26-30
31-35
36-40
41-45
41-50
51-55
56-60
61+
36. From the time you started smoking up until the time you quit, or until
now if you still smoke cigarettes on AVERAGE How Many Cigarettes
had/have you smoked per ?
5 or fewer per day (1/4 pack)
6-10 per day (1/2 pack)
11-15 per day (3/4 Pack)
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16-20 per day (1 pack)
1 ½ pack per day
2 packs per day
More than 2 packs per day
37. If you smoke, which type of tobacco products do you smoke?
Pipe
Cigars
Water Pipes
Others
Current Tobacco Smoker Section:
38.

How many cigarettes do you currently smoke per day?
5 or fewer per day (1/4 pack)
6-10 per day (1/2 pack)
11-15 per day (3/4 Pack)
16-20 per day (1 pack)
1 ½ pack per day
2 packs per day
More than 2 packs per day

39. Family History
Lung Cancer among Family Members? Check all applicable.
Mother
Father
Brother
Sister
Child
40. Do you currently use e-cigarettes?
Yes
No
41. Do you smoke every day?
Yes
No
42. Check all that apply. Have you ever been exposed to the following
substances?
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Arsenic
Asbestos
Beryllium
Cadmium
Diesel fumes
Nikel
Radom
Silica
Environmental Smoke

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