0 rPA United States	Office of
v/CrM Environmental Protection Agency	Research and Development
The Arizona Border Study
An Extension of the
Arizona National Human Exposure Assessment Survey (NHEXAS)Study
Sponsored by the Environmental Health Workgroup of the Border XXI Program
24-hour Food Recall Diary
(English Version)
The University of Arizona
Tucson, Arizona 85721
Cooperative Agreement CR 824719
Source: The University of Arizona
U.S. Environmental Protection Agency
Office of Research and Development
Human Exposure & Atmospheric Sciences Division
Exposure & Dose Research Branch
Notice: The U.S. Environmental Protection Agency (EPA), through its Office of Research and Development (ORD), partially funded
and collaborated in the research described here. This protocol is part of the Quality Systems Implementation Plan (QSIP)
that was reviewed by the EPA and approved for use in this demonstration/scoping study. Mention of trade names or
commercial products does not constitute endorsement or recommendation by EPA for use.

-------
OMB Clearance #: 2080-0053 Expires : 07/31/98
HfflD#	 F.S.
NATIONAL HUMAN EXPOSURE ASSESSMENT SURVEY
24-HOUR FOOD DIARY
Respondent's First Name [ONLY]	
Respondent's IRN #	
Completed On 	/	/	
Mo Day Year
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
and to require 0 hours recordkeeping. This includes the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to Chief, Information Policy Branch, 2136, U.S.
Environmental Protection Agency, 401 M St., S.W., Washington, D.C. 20460; and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.	
OFFICE USE ONLY

COMP TYPE: TECH
SELF
GUARDIAN OTHER
QC

/ /

INIT
MO
DAY
YR
OA

/ /

INIT
MO
DAY
YR
DE

/ /

INIT
MO
DAY
YR
DP BATCH:



-------
NATIONAL HUMAN EXPOSURE ASSESSMENT SURVEY
24-HOUR FOOD DIARY QUESTIONNAIRE
What is the first name of the individual providing responses to these questions?
First name only	IRN#
What is the relationship of this individual to the person for whom the responses are
provided?
Check one:
~
~
~
Is this a tech assisted 24-Hour Food Diary QX? Circle one: Y or N
TECH INITIALS	 TECH ID	
Chain of Custody Initiated (sig.):	
CONSIGNED TO PACKET ON: [ ] I /	BOX UA-G4-2.0
Self
Guardian
Other, specify.

-------
HOW TO USE THE 24-HOUR FOOD DIARY
FOR PARTICIPANTS LESS THAN 10 YEARS OLD, A PARENT OR GUARDIAN SHOULD
PROVIDE ASSISTANCE, AS NEEDED, IN COMPLETING THE FOOD DIARY.
INSTRUCTIONS
(1)	We want you to list all of the foods, beverages, drinking water you or this child eat(s)
or drink(s) from midnight to midnight.
(2)	Every time you or this child eat(s), write down the name of the meal (breakfast, lunch,
dinner, snack).
(3)	Then write down on a separate line the (brand/generic) name of every food, beverage
that you or this child eat(s) or drink(s).
(4)	For food mixtures such as stews or potpies, please write down the major kinds of foods
in the mixture. Use the lines immediately below the one on which the name of the
mixture is entered. In food mixtures, the component ingredients can be identified, for
example—the type of meat in a stew—beef, lamb, venison, etc.
(5)	For beverages (including water), write down how many cups or glasses that you or this
child drink(s). Estimate equivalent measures of water or other beverages taken from a
fountain or large container. Don't forget your second and third cups of coffee or tea, or
refills at a restaurant.
EXAMPLE:
Meal
Please list all foods, beverages, and vitamins
that you or this child eat(s) or drink(s) and
how many of each item
How
Many
Portion
Cooking
Method
Non-
Retail
Source






lunch
Cheeseburger - 1 slice American cheese
1




-1 quarter pound beef patty





- lettuce, tomato slice, onion, ketchup





French Fried Potatoes
2 cups




- ketchup





18 ounce Coca Cola
1




Chocolate Chip Cookies
3



3

-------
NHEXAS FOOD DIARY
START DATE: TIME:
END DATE: TIME:

FOR
INTERVIEWER
USE ONLY
Meal
PLEASE LIST ALL FOODS, BEVERAGES, AND
VITAMINS THAT YOU OR THIS CHILD EAT(S)
OR DRINK(S) AND HOW MANY OF EACH ITEM
How
Many
Portion
Size
Cooking
Method
Non-
Retail
Source
























































































|




!
*
































-



























CONTINUE ON NEXT PAGE IF YOU HAVE MORE FOODS TO UST.
4

-------
3
NHEXAS FOOD DIARY

FOR
INTERVIEWER
USE ONLY
Meal
PLEASE LIST ALL FOODS, BEVERAGES, AND
VITAMINS THAT YOU OR THIS CHILD EAT(S) OR
DRINK(S) AND HOW MANY OF EACH ITEM
How
Many
Portion
Size
Cooking
Method
Non-
Retail
Source











lllllllll




























































































































































5

-------