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 ------- |