0 EDA United States ^u1Sm u 0fficeof
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
Quality Systems and Implementation Plan
for Human Exposure Assessment
The University of Arizona
Tucson, Arizona 85721
Cooperative Agreement CR 824719
Standard Operating Procedure UA-G-QSIP1-B7
Title: Quality Systems and Implementation Plan for Total Human
Exposure in Arizona: A Comparison of the Border Communities
and the State-Appendix B, Part 7
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.
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TECHNICIAN WALK-THROUGH QUESTIONNAIRE
National Human Exposure Assessment Survey
Form Type:
0 8
NHEXAS Form ID:
UA-T-1.0-3.0
l
C/3
O 1.NHEXAS
O 2, Border
O 3.
O 4.
O 5.
:~
Stage #
Collapsed?
Y N 8
o o o
Administered By:
Init.
Tech. ED
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 full 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:
QC / CODING
~ QC
~ -5.R
~ -8.N
~ -9.M
~QC
~ -5.R
~ -8.N
~ -9.M
~ QC :
~ -5.R
~ -8.N
~ -9.M
O 55.R
O 88.N
O 99.M
Dust Com.
5. Indicate nearest major intersection: (Eg., Park and Speedway)
&
OFFICE USE ONLY
3
3
<75
E
i_
£
O l.Cmp
O 2.N Cmj
O 3.PCmp
O 4.Re-col
O 5.Ref
O 7.Dest
O 8.N/A
O 9.Mi*s
Tech. ID
MO
DAY
YR
DE:
/
Init.
DP Batch:
QXV:
Q
T
E
C
1
Public reporting burden foe this collection of information ii catimated 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 cr any other aspect of
this collection of information, including suggestions for reduciig the burdrn, 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 Regulatay 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
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EXTERIOR AND INTERIOR RESIDENTIAL CHARACTERISTICS PAGE 2
Technician Qx
6 a. Surrounding area (within a quarter mile radius of this property): Fill In bubbles of ALL
THAT APPLY.
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):
6 c. Exterior siding material (including foundation):
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:
Fill bubble if true:
OR 0 1. Curb is > 300 feet from primary entrance
Fill In bubbles of ALL THAT APPLY.
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
6 f. Material around primary entrance to structure: Fill in bubbles of ALL THA T APPLY.
O 1. Soil (Primary entrance ¦ most often used.)
2. Grass
3. Cement / asphalt / brick
4. Gravel
5. Wood (If deck, yes; if door frame, no.)
6. Other (specify:
O
O
O
o
o
QC / CODING
O 55.R
O 88.N
O 99.M
O Area
O 55. R
O 88. N
O 99. M
O 55.R
O 88.N
O 99. M
0 Skfirtg:
O 55.R
O 88. N
O 99. M
O 55.R
O 88. N
O 99. M
O 55, R
O 88, N
O 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 o
o o
O 0
0 o
0 o
0 0
o o
O 0
941
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HMD:
FS:
PAGE 3
Technician Qx
6 g. Dripline: Fill In ONE bubble.
O 1. At wall
O 2. Gutters - no dripline
Dripline ft. from wall:
O
O
feet from wall
3.
4. Other (specify:.
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 THA T 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
Fill In ONE bubble.
7 a. Does this residence have a swimming pool?
O 1. Yes Continue below
O 2. No GO TO Question#8 a
7 b. Where is the swimming pool located? Fill in ONE bubble.
O 1. Inside O 2. Outside
8 a. Does this house or apartment have a hot tub or jacuzzi?
O 1. Yes Continue below
O 2. No sTOP
Fill in ONE bubble.
8 b. Where is the hot tub or jacuzzi located? Fill in ONE bubble.
O 1. Inside O 2. Outside
QC/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
0 Found:
O 55. R
O 88.N
O 99.M
O 55.R
O 88.N
O 99. M
O 55. R
O 88. N
O 99 M
yjV+vVtHHiTVTf+yjyv-v-
O 55. R
O 88.N
O 99. M
Data Use
0 1
2 3
4 J
6 7
8 9
A B
C D
E F
O H
i j
Only:
O O
o o
o o
o o
o o
o o
O O
o o
O O
o o
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SUBJECT TRACKING
PAGE 4
Technician Qx
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
c.
e
f.
h
j-
k.
m.
~QC
0-5JL
a-***
0-9.M
~QC
D X'sJR.
~ rs.N
~ Z'S.M
~ QC ~ 53/55/55.R
~ 88/8&/88.N
~ 99/9SV99.M
Data Use
0 1
2 3
4 5
6 7
8 9
A B
C D
E F
G H
I J
Only:
0 0
O O
O O
O O
0 0
O O
O O
O O
O O
O O
941
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HHJD: FS:
——Tl SUBJECT TRACKING (Cont.) PAGE 5
Technician Qx
Commen
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)
0 o o
h
Y N 8 (def)
o o o
j
0,
Y N 8 (def)
o o o
d
Y N 8 (def)
O O 0
e.
Y N 8 (def)
o o o
f
Y N 8 (def)
o o o
9
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 o
k
Y N 8 (def)
O 0 o
I
Y N 8 (def)
O 0 0
m,
Y N 8 (def)
o o o
~QC
~QC
~ QC Q-5.R
~QC D-5.R
~ QC Q-5.R
lioiiiiiii
~-8.N
~ -8.N
~ -8.N
Q-9.M
~ -9.M
~-9JM
•• ••••• •• • • •
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
0 o
o
o
O 0
o o
O 0
941
lis
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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.
{Room_d|mension8 are ttHrarounded tojhenearest foot)
10 c. Indicate room(s) where samples are collected:
PM
MR O
LR O
FR O
KA O
boT o
B02 O
B03 O
B04 O
ORt O
OR2 O
OR3 O
OR4 O
OR5 O
OK6 Q
AMB O
R O
N O
M O
Carpet
Dust
MR O
LR O
FR O
KA O:
"ioi O
B02 O
B03 O
KM O
ORl O
OR2 O
OR3 O:
OR4 O:
taw O:
OR* Oi
AMB O
R Oi
K Oi
M Oi
Surface
Oust
MR
LR
FR
o
o
o
KA. O
B01 6"
B02
B03
o
o
804 9
ORl o
OR2 O
-------
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