se of
earch 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
Technician Walk-through Questionnaire
(Spanish 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.
-------
g| TECHNICIAN WALK-THROUGH QUESTIONNAIRE g
National Human Exposure Assessment Survey
Form Type:
. 0 8
NHEXAS Form ID:
UA-T-1.0-3.0
£5
O 1. NHEXAS
O 2. Border
O 3.
O 4.
O 5.
Stage #:
Collapsed?
Y
o
N 8
o o
Administered By:
Init.
Tech. ID
HMD
F.S.
Administration Date
/
/
MO
DAY
YR
Complete this questionnaire by observation. You may ask participant any questions that
are not apparent
1. How many stories (floors) are in this building? Count only floors with finished rooms for
living purposes or fuU basements. (Do not include sub-basements.)
Floor(s):
If multi-family building — Continue
Else — Go to question #3
2. Which floor(s) do respondents live on? List each floor.
Floor#:
Floor#:
Floor#:
Floor#:
Floor#:
3. How many rooms are carpeted or have rugs covering most (>50%) of their surface?
[ ] N/A or no room(s) is carpeted.
Rooms:
4. Using the following statements, how would you rate the overall dust level within the residence?
Fill in ONE bubble.
O 1. Very Dusty
O 2. Some Dust - obvious efforts to control dust
O 3. "No" Dust - extreme dust control, very clean
Additional Comments on dust control:
5. indicate nearest major intersection: (Eg., Park and Speedway)
&
QCI CODING
iomm
iHliil
Hllli
G-9.M
~ QC
ioii!i
Dili!;
fiflii
fopii
oiiii
7-8N
~ -9.M
55 R
(. 88.N
C 99 M
Dust Com
OFFICE USE ONLY
3
S
u
O
u.
O l.Cmp
O 2.N Cmr
O 3.P Cmp
o 4.Re-col
O 5-Ref
O 7-Dest
O 8.N/A
O 9.Miss
Tech. ID
MO
DAY
YR
Tech. ID
MO
DAY
YR
QC:
QA:
Init.
Init.
/
/
DE:
/
Init.
DP Batch:
QXV:
QTEC1
Public reporting burden for this collection of information is estimated to average 5 minutes per completion, and to require 0 hours recordkeeping. This includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, 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 Chiefs 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. OMB Clearance #: 2080-0053 Expires: 07/31/98
Data Use
0 1
2 3
4 5
6 7
8 9
A B
c
D
E F
G
H
I J
Only:
O O
o o
o o
o o
o o
o o
o
o
o o
o
o
o o
941
tevl
-------
EXTERIOR AND INTERIOR RESIDENTIAL CHARACTERISTICS
PAGE 2
Technician Qx
6 a. Surrounding area (within a quarter mile radius of this property):
THAT APPLY.
Fill in bubbles of ALL
o
1.
Residential
o
2.
Recreational
o
3.
Commercial
o
4.
Industrial
o
5.
Agricultural
o
6.
Other (specify:
(Shade bubbles of dominant land uses.)
6 b. Distance to street:
Measure the distance from the curb to the primary entrance to the residence or shade
bubble if distance is estimated to be greater than 300 feet
Feet (<300):
OR
Fill bubble if true:
O 1. Curb is > 300 feet from primary entrance
6 c. Exterior siding material (including foundation): Fill in bubbles of ALL THAT APPLY.
O
1.
Wood
O
2.
Brick
o
3.
Vinyl / aluminum
o
4.
Concrete block
o
5.
Stucco
o
6.
Asbestos / asphalt
o
7.
Other (specify:
6 d. Is there paint on any exterior surface that is chalking, chipping, or peeling? Fill in ONE
bubble.
O 1. Yes
O 2. No
O 3. Not painted
6 e. Is there paint on any interior surface that is chalking, chipping, or peeling? Fill in ONE
bubble.
O 1. Yes
O 2. No
O 3. Not painted
6f. Material around primary entrance to structure: Fill in bubbles of ALL THAT APPLY.
q ^ 0oj| (Primary entrance = most often used.)
O 2. Grass
O 3. Cement / asphalt / brick
O 4. Gravel
O 5 Wood W deck, yes; ^oor frame>no)
O 6. Other (specify:
QC / CODING
O 55.R
C 88.N
C 99. M
O Area
O 55 R
O 88 N
O 99. M
O 55. R
O 88. N
O 99. M
0 Siding.
1
55 R
O 88.N
C 99.M
?¦ 55.R
O 88.N
<:¦ 99 M
O 55. R
O 88.N
C 99. M
O Material:
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G
H
I J
Only:
O O
o o
O 0
o o
o o
o o
O O
o o
o
o
o o
941
£3
-------
FS:
PAGE 3
Technician Qx
6 g. Dripline: Fill in ONE bubble.
O 1. At wall
O 2. Gutters - no dripline
O 3. feet from wall-
O 4. Other (specify:
Dripline ft. from wall:
6 h.
Roof type and composition:
1. Tarred roof — petroleum base
2. Sealed with roof protector
3. Wood shakes / shingles
4. Composition asphalt shingles
5. Other (specify:
Fill in bubbles of ALL THAT APPLY.
O
O
o
o
o
6 i. Yard material: Fill in bubbles of ALL THAT APPLY.
o
1.
Soil
o
2.
Grass
o
3.
Porch / balcony
o
4.
Cement
o
5.
Wood / deck
o
6.
Other (specify:
o
7.
Not applicable
6 j. Types of foundation: Fill in bubbles of ALL THAT APPLY.
O 1. Slab
O 2. Crawl space
O 3. Combination crawl space / basement
O 4. Full basement
O 5. Other (specify:
O 6. Don't know
7 a. Does this residence have a swimming pool? Fill in ONE bubble.
O 1. Yes Continue below
O 2. No GO TO Question #3 a
7 b.
3 a.
Where is the swimming pool located? Fill in ONE bubble.
O 1. Inside O 2. Outside
Does this house or apartment have a hot tub or jacuzzi? Fill in ONE bubble.
O 1. Yes Continue below
O 2. No ••••
STOP
8 b. Where is the hot tub or jacuzzi located? Fill in ONE bubble.
O 1. Inside O 2. Outside
QCI CODING
O 55.R
O 88.N
O 99.M
O Dripline:
O 55.R
O 88.N
O 99.M
ORoof:
O 55.R
O 88.N (def.)
O 99. M
OMat.:
O 55.R
O 88.N
O 99.M
O Found:
O 55.R
O 88.N
O 99.M
wo
55.R
:::0
88.N
I;iO
99.M
To
55.R
Z:0
88.N
m
99.M
O 55.R
O 88.N
O 99.M
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G
H
I J
Only:
O O
o o
o o
o o
o o
o o
O O
o o
o
(J
o o
941
E3
-------
SUBJECT TRACKING
PAGE 4
9. Subject Tracking (Arizona Only)
It is vital that the subject number is assigned consistently. Respondent numbers were assigned during the
initial contact. Prior to entering the field, record the preassigned respondent numbers and the first name of
the subject. Verify the previous information and record additional information. Record the names and status
of any previously absent or unreported household members. Assign additional houshold members a
respondent number, and notify the Field Coordinator of any changes immediately upon return to the Field
Office.
Pre-Assigned
IRN
Legal First Name
Date of Birth
MO DAY YR
Comments:
a
/
b
/
/
c.
/
/
d
/
/
e
/
/
f.
I
/
/
g
/
/
h
/
/
i.
/
/
j-
/
/
k.
/
/
I.
/
/
m.
/
/
~ QC Q-5.R
~ -8.N
~-9.M
- f Qic: ~ X's.R: . : '
~ Y's.N
M : ~ Z'S.M
~ 88/88/88.N
~ 99/99/99.M
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G H
I J
Only:
O O
o o
o o
o o
o o
o o
O O
o o
o o
o o
941
-------
SUBJECT TRACKING (Cont.)
PAGE 5
Comments: — ——
Resp.
IRN
Relationship to
Respondent 01
Relat. Code
Bedrm#
(from
diaaram)
IRN#
During This
Visit Series
Change in
Respondent
Status
Comments:
a,
Y N 8 (def)
o o o
b.
Y N 8 (def)
o o o
c,
Y N 8 (def)
o o o
-
d.
Y N 8 (def)
o o o
e.
Y N 8 (def)
o o o
f
Y N 8 (def)
o o o
g- —
Y N 8 (def)
o o o
h
Y N 8 (def)
o o o
i
Y N 8 (def)
o o o
j-
Y N 8 (def)
O O 0
k
Y N 8 (def)
O O 0
I
Y N 8 (def)
o o o
m.
Y N 8 (def)
o o o
~ QC
lliltlDtii
S:<2e:C- 0--M
C-8.N
~ -9.M i
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G H
I J
Only:
O O
o o
o o
o o
o o
o o
O O
o o
o o
o o
941
fiS
-------
HOUSEHOLD DIAGRAM
PAGE 6
Technician Qx
10 a. Overall (approximate) dimensions of the portion of the house or apartment occupied by the residents:
Average Length:
ft. Average Width:
ft. Ceiling Height:
ft.
10 b. Diagram the house and approximate dimensions of each room. Label the Main Room (MR) and the Living Room (LR) or
Family Room (FR) if different from the Main Room. Label the Kitchen (KA), and any Other Room (OR). As a convention
label the Bedrooms in order of size (B01 = largest, B02 = next largest). Bedrooms of equal size can be labeled arbitrarily.
(Roomdjmensions are jo_bej;qunded tothenearest foot)
10 c. Indicate room(s) where samples are collected :
PM
Carpet
Dust
Surface
Dust
PID
Active
voc
Passive
voc
Passsive
HCHO
Other A:
Other B:
MR
O;
MR
ol
MR
Ol
MR
o
MR
o
MR
O
MR
o:
MR
Ol
MR
O
: LR
O
LR
o
LR
Ol
LR
o;
LR
o
LR
O
LR
o>
LR
o
LR
O:
FR
O
FR
oi
FR
ol
FR
Ol
FR
o
FR
o
FR
c
FR
o
FR
o
KA
G
KA
Ol
KA
o
KA
o
KA
O-
KA
o:
KA
Ol
KA
O:
KA
o
B01
O
B01
o
B01
o
B01
o
B01
o
B01
O
BOl
o
BOl
O
BOl
o
B02
O
B02
o
B02
o
B02
o
B02
o
B02
O
B02
o
B02
o
B02
o
B03
O
B03
o
B03
o
B03
o
B03
o
B03
O
B03
o
B03
o
B03
o
B04
O
B04
o
B04
o
B04
o
B04
o
B04
O
B04
o
B04
o
B04
o
OR1
O
OR1
o
ORl
o
ORl
Ol;
ORl
Ol
ORl
O:
ORl
o
ORl
o
ORl
o
OR2
O
OR2
o.
OR2
Ol
OR2
Ol
OR2
Ol
OR2
Ol
OR2
o
OR2
o
llOR2|
o
OR3
O
OR3
o
OR3
Ol
OR3
Ol
OR3
Ol
OR3
0
OR3
o
OR3
0
OR3
Ol
OR4
O
OR4
c
OR4
Ol
OR4
Ol
OR4
Ol
0R4
0?
OR4
0
OR4
0
IliiORil
o|
OR5
O
OR5
c
OR5
Ol
OR5
Ol
OR5
o
0R5
o;
0R3
o
OR5
o
llopl
c
OR6
C
OR6
ol
OR6
o
OR6
Ol
OR6
0
OR6
C
OR6
o
OR6
o
OR6
G
AMB O
AM B 0 1
AMB O
AMB O
AMB 0
AMB O
AMB 0
AMB 0
AMB O
R
O
R
Ol
R
Ol
iillll
Ol
Iltllll:
o
wmm.
O:
1:!R|!!
c
MmB
o
!!!&!!!!
o
N
Ol
lliiili
O
Mil!
Ol
Ililll
Ol
iliillll
Ol
wmg?
O
lllN:|;ll
o
ipsii
o
Hii
o
M
Ol
lliiili
Ol
llMllll
O
IImiiii
o
lllMlll;
Ol
:1IM;|:::0
O
IIIM?*:
o
lllMIll
o
lliiili;
o
10 d. Personal
Air:
[ ] N/A
or
IRN #:
If applicable, write names
of any other rooms (OR)
on line(s) below:
OR1
OR2
OR3
OR4
OR5
OR6
O. Samp A: O. Samp B:
CODING
ORt:
OR2:
0R3:
OR4:
OR5:
0R6:
Pagdink QC
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G H
I J
lnit:;
Only:
O O
o o
o o
0 o
o o
o o
O O
o o
o o
o o
941
-------
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