1 Survey

A ppendix A A.2.3.p–5

National Children’s study

24 mo - vacuum dust questionnaire

draft only - not for distribution

• Use only a black, ball-point pen. Do not use a pencil or felt-tip pen.

• Put an X in the box next to your answer.

• If you make any changes, put a line through the incorrect answer  and put an X in the box next to the correct answer. Also, draw a circle around the correct answer .

1. Please record the date you collected the vacuum sample:

MONTH	DAY		YEAR
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	0	0	2008 2009 2010 2011 2012 2013 2014 2015
	1	1
	2	2
	3	3
		4
		5
		6
		7
		8
		9

2. Did you vacuum the bed?

₀ No  go to 7

₁ Yes

3. Where is this bed located:?

₁ Child’s bedroom

₂ Shared area of the home

4. Record the type of bed you sampled.

₁ Mattress bed/crib

₂ Sleeper sofa

₃ Sofa

₄ Inflatable/water bed

₆ Other (specify) ___________________

_ _

5. How much of the bed did you vacuum?

₁ All the area in the measuring square

₂ Less area than in the measuring square

₃ More than the area in the measuring square

₆ Other, specify: ___________________

_ _

6. Please write in how long you, in minutes, that you vacuumed the bed?

____________ minutes

7. Did you vacuum the floor?

₀ No

₁ Yes

8. Record the type of floor you vacuumed.

₁ Tile or Linoleum

₂ Wood floor

₃ Room-sized rug or wall-to-wall carpet

₄ Small area rug

₆ Other, specify: ___________________

9. How much of the floor did you vacuum?

₁ All the area in the measuring square

₂ Less area than in the measuring square

₃ More than the area in the measuring square

₆ Other, specify: ___________________

_ _

10. Please write in how long you, in minutes, that you vacuumed the floor?

____________ minutes

7. When was the last time you cleaned (swept, vacuumed, dusted, or mopped) the floor you vacuumed?

₁ Less than five days before taking the sample

₂ More than five days before taking the sample

THANK YOU VERY MUCH FOR COMPLETING THIS QUESTIONNAIRE! ALL OF YOUR ANSWERS ARE VERY IMPORTANT.