Questionnaire

Appendix F

Katrina Registry Pilot Questionnaire

Form Approved

OMB No. 0923-XXXX

Expiration Date: XX/XX/20XX

________________________________________________________________________

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

________________________________________________________________________

Katrina Pilot Registry Main Interview

EX0. First, I have some questions about the FEMA homes that you lived in, stayed at, or visited after Hurricanes Katrina and Rita.

EX1. For the following questions, please think about the first FEMA home you lived or stayed in for at least seven consecutive days. What type of home was it? What it a …

INTERVIEWER: A FEMA home does not include HOUSING rentals. A FEMA home refers to a temporary housing unit such as a travel trailer, park model, or mobile home. The HOME DID NOT HAVE TO BE REGISTERED TO RESPONDENT.

 Travel trailer, which is towed by another vehicle, and used for recreation, camping, or travel

 Park model, which is bigger than a travel trailer and typically has one bedroom and a fold-out couch (in traveling mode, is less than 40 feet long)

 Mobile home, which is bigger than a travel trailer or a park model and is about 60 feet long and 14 feet wide (also known as a “manufactured homes”)

 DON’T KNOW

 REFUSED

EX2. Including (yourself/SUBJECT), how many people ever lived or stayed in the (Travel Trailer/Mobile Home/Park Model/Home) while (you were/SUBJECT was) there? Please include only people who stayed at least seven consecutive days in the (Travel Trailer/Mobile Home/Park Model/Home).

_____ Number of people

IF EX2 IS ONE → GO TO EX4A.

EX3. I have a few questions about the [EX2 MINUS ONE] other (people/person) who lived or stayed in the (Travel Trailer/Mobile Home/Park Model/Home) while you were there. Could you please tell me one person’s first and last names?

INTERVIEWER: IF NECESSARY, SAY: “As we discussed earlier, your participation in the registry may involve being interviewed every few years. If we have difficulty contacting you in the future, we may contact individuals who can help us get in touch with you. We will not contact these individuals for any other purpose. We will not share any of your answers with these individuals.”

(COMPLETE GRID, ASKING ALL QUESTIONS BEFORE CONTINUING TO THE NEXT PERSON. DO NOT INCLUDE RESPONDENT.)

Person	A. What was this person’s first and last name?	B. Is [FIRST NAME] male or female?	C. What is [FIRST NAME]’s current age? INTERVIEWER: IF PERSON IS DECEASED ASK: “What would their age have been now?”	D. What month is [FIRST NAME]’s birthday in?	E. What is [FIRST NAME]’s race? (ACCEPT MULTIPLE RESPONSES.)	F. Is [FIRST NAME] Hispanic or Latino/a?	G. What is the highest level of education [FIRST NAME] completed?
1	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
2	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
3	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
4	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
5	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
6	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF

EX4A. In what year did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? DO NOT READ RESPONSES.

 2005  2006  2007  DON’T KNOW  REFUSED

 2008  2009  2010

EX4B. In what month in [FILL YEAR FROM EX4A] did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)?

You can look at the brochure we sent you earlier to help you answer this question.

 January  February  March  April

 May  June  July  August

 September  October  November  December

 Don’t Know  Refused

DID RESPONDENT SAY THEY started living or staying there BEFORE AUGUST 2005 (WHEN KATRINA OCCURRED)? IF SO, revise answers to be in or after august 2005.

IF EX4B = DK:

EX4B_DK. Was it in the spring, summer, fall, or winter of [FILL YEAR FROM EX4A]?

 SPRING  SUMMER  FALL  WINTER

 Don’t Know → go to ex5A  Refused → go to ex5A

EX4C. On what day in [FILL MONTH AND YEAR FROM EX4A, EX4B] did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? Again, you can look at the brochure we sent you earlier to help you answer this question. PROBE AS NECESSARY.

_____ Day  DON’T KNOW  REFUSED

IF EX4C = DK:

EX4C_DK. Was it at the beginning of the month, the middle of the month, or the end of the month?

 BEGINNING  MIDDLE  END

 Don’t Know  Refused

EX5A. In what year did you stop living or staying in this (Travel Trailer/Mobile Home/Park Model/Home)? DO NOT READ RESPONSES.

 2005  2006  2007  2008  2009  2010

 DON’T KNOW  REFUSED

EX5B. In what month in [FILL YEAR FROM EX5A] did you stop living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? You can look at the brochure we sent you earlier to help you answer this question.

 January  February  March  April

 May  June  July  August

 September  October  November  December

 Don’t Know  Refused

IF EX5B = DK:

EX5B_DK. Was it in the spring, summer, fall, or winter of [FILL YEAR FROM EX5A]?

 SPRING  SUMMER  FALL  WINTER

 Don’t Know  Refused

EX5C. On what day in [FILL MONTH AND YEAR FROM EX5A, EX5B] did you stop living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? Again, you can look at the brochure we sent you earlier to help you answer this question. PROBE AS NECESSARY.

_____ Day  Don’t Know  Refused

IF EX5C = DK:

EX5C_DK. Was it at the beginning of the month, the middle of the month, or the end of the month?

 BEGINNING  MIDDLE  END

 Don’t Know  Refused

EX_CHECK1. Could we take a minute to review your answers? You said you started living or staying in the (Travel Trailer/Mobile Home/Park Model/Home) on [FILL FROM EX4 SERIES], and stopped living or staying there on [FILL FROM EX5 SERIES]. This means you stayed in the trailer for [FILL TIME]. Does this sound right, or do you want to change your answers?

 ANSWERS ARE RIGHT → CONTINUE

 CHANGE ANSWERS → PROBE RESPONDENT FOR INCORRECT ANSWERS

EX_AWAY1. Did you ever spend a week or more away from the (Travel Trailer/Mobile Home/Park Model/Home) while you were living or staying there?

 YES → go to ex_away2  Don’t Know → go to ex6A

 NO → go to ex6a  Refused → go to ex6A

_________________________________________________________________________________

EX_AWAY2. In total, how long were you away from the (Travel Trailer/Mobile Home/Park Model/Home)? INTERVIEWER: IF NECESSARY, SAY: How many days, weeks, or months in total?

INTERVIEWER: CODE THE TOTAL NUMBER OF DAYS, WEEKS OR MONTHS.

___ # of days

___ # of weeks

___ # of months

EX6A. Between [FILL DATE] and [FILL DATE], how many nights a week did you usually sleep in the (Travel Trailer/Mobile Home/Park Model/Home)?

____ Nights  Don’t Know  Refused

EX6B. On a typical night, how many hours did you sleep in the (Travel Trailer/Mobile Home/Park Model/Home)?

____ Hours  Don’t Know  Refused

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

EX6C. On a typical weekday—that is, any day Monday through Friday— about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

EX6D. On a typical Saturday, about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

EX6E. On a typical Sunday, about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

_____________________________________________________________________________________

EX_TIME1. After you stopped living or staying in (Travel Trailer/Mobile Home/Park Model/Home), did you ever spend time in the (Travel Trailer/Mobile Home/Park Model/Home), even just for a few hours?

 YES → go to ex_time2  DON’T KNOW → go to ex7
 NO → go to ex7  Refused → go to ex7

_____________________________________________________________________________________

EX_TIME2. How much time did you spend in the (Travel Trailer/Mobile Home/Park Model/Home) after you stopped living or staying there?

INTERVIEWER: CODE NUMBER OF HOURS PER DAY, WEEK, OR MONTH:

1. ___ # of hours

2.  Per day  Per week  Per month

3. ___ # of days, weeks, months (as indicated in B)

____________________________________________________________________________________

EX7. In addition to the (Travel Trailer/Mobile Home/Park Model/Home) you just told me about, which you stayed from in [FILL] to [FILL], did you live in, stay at, or visit another FEMA home for at least seven consecutive days?

 YES → GO TO EX8  Don’t Know

 NO → GO TO EX14  Refused

EX8. For the following questions, please think about this second FEMA home you lived or stayed in for at least seven consecutive days. What type of home was it?

INTERVIEWER: A FEMA home does not include HOUSING rentals. A FEMA home refers to a temporary housing unit such as a travel trailer, park model, or mobile home. The HOME DID NOT HAVE TO BE REGISTERED TO RESPONDENT.

 Travel trailer, which is towed by another vehicle, and used for recreation, camping, or travel

 Park model, which is bigger than a travel trailer and typically has one bedroom and a fold-out couch (in traveling mode, is less than 40 feet long)

 Mobile home, which is bigger than a travel trailer or a park model and is about 60 feet long and 14 feet wide (also known as a “manufactured homes”)

 DON’T KNOW

 REFUSED

EX9. Including (yourself/SUBJECT), how many people ever lived or stayed in the (Travel Trailer/Mobile Home/Park Model/Home) while (you were/SUBJECT was) there? Please include only people who stayed at least seven consecutive days.

_____ ENTER NUMBER

INTERVIEWER: IF EX9 IS ONE → GO TO EX11.

EX10. I have a few questions about the [EX9 MINUS ONE] other (people/person) who lived or stayed in the (Travel Trailer/Mobile Home/Park Model/Home) while you were there. Could you please tell me one person’s first and last names?

INTERVIEWER: IF NECESSARY, SAY: “As we discussed earlier, your participation in the registry may involve being interviewed every few years. If we have difficulty contacting you in the future, we may contact individuals who can help us get in touch with you. We will not contact these individuals for any other purpose. We will not share any of your answers with these individuals.”

(COMPLETE GRID, ASKING ALL QUESTIONS BEFORE CONTINUING TO THE NEXT PERSON. DO NOT INCLUDE RESPONDENT.)

Person	A. What was this person’s first and last name?	B. Is [FIRST NAME] male or female?	C. What is [FIRST NAME]’s current age? INTERVIEWER: IF PERSON IS DECEASED ASK: “What would their age have been now?”	D. What month is [FIRST NAME]’s birthday in?	E. What is [FIRST NAME]’s race? (ACCEPT MULTIPLE RESPONSES.)	F. Is [FIRST NAME] Hispanic or Latino/a?	G. What is the highest level of education [FIRST NAME] completed?
1	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
2	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
3	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
4	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
5	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF
6	____________ ____________  DK  REF	 M  F	______ Age  DK  REF	 JAN.  JUL.  FEB.  AUG.  MAR  SEP.  APR.  OCT.  MAY  NOV.  JUN.  DEC.  DK  REF	 White or Caucasian  Black or African-American  Asian  Nat. Hawaiian or Pac. Isl.  Am. Ind. or Alaska Native  DK  REF	 YES  NO  DK  REF	 Less than HS  High school degree  Some college  Bachelor’s degree  Advanced degree  DK  REF

EX11A. In what year did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? DO NOT READ RESPONSES.

 2005  2006  2007  DON’T KNOW  REFUSED

 2008  2009  2010

EX11B. In what month in [FILL YEAR FROM EX11A] did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)?

You can look at the brochure we sent you earlier to help you answer this question.

 January  February  March  April

 May  June  July  August

 September  October  November  December

 Don’t Know  Refused

DID RESPONDENT SAY THEY STARTED LIVING OR STAYING THERE BEFORE AUGUST 2005 (WHEN KATRINA OCCURRED)? IF SO, revise answers to be in or after august 2005.

IF EX11B = DK:

EX11B_DK. Was it in the spring, summer, fall, or winter of [FILL YEAR FROM EX11A]?

 SPRING  SUMMER  FALL  WINTER

 Don’t Know → go to e12A  Refused → go to e12A

EX11C. On what day in [FILL MONTH AND YEAR FROM EX11A, EX11B] did you start living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? Again, you can look at the brochure we sent you earlier to help you answer this question. PROBE AS NECESSARY.

_____ Day  DON’T KNOW  REFUSED

IF EX11C = DK:

EX11C_DK. Was it at the beginning of the month, the middle of the month, or the end of the month?

 BEGINNING  MIDDLE  END

 Don’t Know  Refused

EX12A. In what year did you stop living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? DO NOT READ RESPONSES.

 2005  2006  2007  2008  2009  2010

 DON’T KNOW  REFUSED

EX12B. In what month in [FILL YEAR FROM EX5A] did you stop living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? You can look at the brochure we sent you earlier to help you answer this question.

 January  February  March  April

 May  June  July  August

 September  October  November  December

 Don’t Know  Refused

IF EX12B = DK:

EX12B_DK. Was it in the spring, summer, fall, or winter of [FILL YEAR FROM EX12A]?

 SPRING  SUMMER  FALL  WINTER

 Don’t Know  Refused

EX12C. On what day in [FILL MONTH AND YEAR FROM EX12A, EX12B] did you stop living or staying in the (Travel Trailer/Mobile Home/Park Model/Home)? Again, you can look at the brochure we sent you earlier to help you answer this question. PROBE AS NECESSARY.

_____ Day  Don’t Know  Refused

IF EX12C = DK:

EX12C_DK. Was it at the beginning of the month, the middle of the month, or the end of the month?

 BEGINNING  MIDDLE  END

 Don’t Know  Refused

EX_CHECK2. Could we take a minute to review your answers? You said you started living or staying in the (Travel Trailer/Mobile Home/Park Model/Home) on [FILL FROM EX11 SERIES], and stopped living or staying there on [FILL FROM EX12 SERIES]. This means you stayed in the trailer for [FILL TIME]. Does this sound right, or do you want to change your answers?

 ANSWERS ARE RIGHT → CONTINUE

 CHANGE ANSWERS → PROBE RESPONDENT FOR INCORRECT ANSWERS

EX_AWAY3. Did you ever spend a week or more away from the (Travel Trailer/Mobile Home/Park Model/Home) while you were living or staying there?

 YES → go to ex_away4  Don’t Know → go to ex13A

 NO → go to ex13a  Refused → go to ex13A

_________________________________________________________________________________

EX_AWAY4. In total, how long were you away from the (Travel Trailer/Mobile Home/Park Model/Home)? INTERVIEWER: IF NECESSARY, SAY: How many days, weeks, or months in total?

INTERVIEWER: CODE THE TOTAL NUMBER OF DAYS, WEEKS OR MONTHS.

___ # of days

___ # of weeks

___ # of months

______________________________________________________________________________

EX13A. Between [FILL DATE] and [FILL DATE], how many nights a week did you usually sleep in the (Travel Trailer/Mobile Home/Park Model/Home)?

____ Nights  Don’t Know  Refused

EX13B. On a typical night, how many hours did you sleep in the (Travel Trailer/Mobile Home/Park Model/Home)?

____ Hours  Don’t Know  Refused

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

EX13C. On a typical weekday—that is, any day Monday through Friday— about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

EX13D. On a typical Saturday, about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

EX13E. On a typical Sunday, about how many hours did you usually spend awake inside the (Travel Trailer/Mobile Home/Park Model/Home)?

INTERVIEWER: IF NECESSARY, SAY: “Your best guess is fine” or “Can you give me an average number of hours?”

____ Hours  Don’t Know  Refused

_____________________________________________________________________________________

EX_TIME3. After you stopped living or staying in the (Travel Trailer/Mobile Home/Park Model/Home), did you ever spend time in the (Travel Trailer/Mobile Home/Park Model/Home), even just for a few hours?

 YES → go to ex_time4  DON’T KNOW → go to ex14
 NO → go to ex14  Refused → go to ex14

__________________________________________________________________________________

EX_TIME4. How much time did you spend in the (Travel Trailer/Mobile Home/Park Model/Home) after you stopped living or staying there?

INTERVIEWER: CODE NUMBER OF HOURS PER DAY, WEEK, OR MONTH:

1. ___ # of hours

2.  Per day  Per week  Per month

3. ___ # of days, weeks, months (as indicated in B)

____________________________________________________________________________________

EX14. Since living or staying in the (Travel Trailer/Mobile Home/Park Model/Home), did you ever permanently move back to the home you lived in before Hurricanes Katrina and Rita?

 YES → CONTINUE TO EX15A

 NO → GO TO HLTH1

 DON’T KNOW → GO TO HLTH1

 REFUSED → GO TO HLTH1

EX15A. In what year did you first permanently move back to the home you lived in before Hurricanes Katrina and Rita?

DO NOT READ RESPONSES.

 2005  2006  2007  2008

 2009  2010  2011

 DON’T KNOW  REFUSED

EX15B. In what month did you first permanently move back to the home you lived in before Hurricanes Katrina and Rita?

 January  February  March  April

 May  June  July  August

 September  October  November  December

 Don’t Know  Refused

IF EX15B = DK:

EX15_DK. Was it in the spring, summer, fall, or winter of [FILL YEAR FROM EX15A]?

 SPRING  SUMMER  FALL  WINTER

 Don’t Know  Refused

HLTH0. Now I have some questions about your health.

HLTH1. (Do you/Does SUBJECT) usually cough on most days for 3 consecutive months or more during the year?

 YES

 NO → GO TO HLTH3

 DON’T KNOW → GO TO HLTH3

 REFUSED → GO TO HLTH3

HLTH2. For how many years (have you/has SUBJECT) had this cough?

(If less than 1 year, enter 1.)

______ Number of years

 DON’T KNOW

 REFUSED

HLTH3 (Do you/Does SUBJECT) bring up phlegm on most days for 3 consecutive months or more

during the year?

 YES

 NO → GO TO HLTH5

 DON’T KNOW → GO TO HLTH5

 REFUSED → GO TO HLTH5

HLTH4. For how many years (have you/has SUBJECT) had trouble with phlegm?

(If less than 1 year, enter 1.)

______ Number of years

 DON’T KNOW

 REFUSED

HLTH5. In the past 12 months (have you/has SUBJECT) had wheezing or whistling in (your/his/her)

chest?

 YES

 NO → GO TO HLTH13

 DON’T KNOW → GO TO HLTH13

 REFUSED → GO TO HLTH13

HLTH6. In the past 12 months, how many attacks of wheezing or whistling (have you/has SUBJECT)

had? (IF 12 OR MORE EPISODES, ENTER 12.)

______ Number of episodes

 DON’T KNOW

 REFUSED

HLTH7. In the past 12 months, how often, on average, has (your/SUBJECT’s) sleep been disturbed

because of wheezing? Would you say this happens...

 Never

 1 or more nights per week

 Less than 1 night per week

 DON’T KNOW

 REFUSED

HLTH8. In the past 12 months, has (your/SUBJECT’s) chest sounded wheezy during or after exercise or physical activity?

 YES

 NO

 DON’T KNOW

 REFUSED

HLTH9. [In the past 12 months], how many times (have you/has SUBJECT) gone to the doctor’s office

or the hospital emergency room for one or more of these attacks of wheezing or whistling?

(If never, enter 0.)

______ Number of times

 DON’T KNOW

 REFUSED

HLTH10. In the past 12 months, (have you/has SUBJECT) taken any medication, prescribed by a

doctor, for wheezing or whistling?

 YES

 NO

 DON’T KNOW

 REFUSED

HLTH11. During the past 12 months, how much did (you/SUBJECT) limit (your/his/her) usual activities due to wheezing or whistling? Would you say...

 Not at all

 A little

 A fair amount

 A moderate amount

 A lot

 DON’T KNOW

 REFUSED

HLTH12. During the past 12 months, how many days of work or school did (you/SUBJECT) miss due

to wheezing or whistling?

 None

 1 to 7

 8 to 30

 31 plus

 DON’T KNOW

 REFUSED

HLTH13. In the past 12 months, (have you/has SUBJECT) had a dry cough at night not counting a cough associated with a cold or chest infection lasting 14 days or more?

 YES

 NO

 DON’T KNOW

 REFUSED

HLTH14. (Have you/Has SUBJECT) had shortness of breath either when hurrying on the level or walking up a slight hill?

 YES

 NO

 DON’T KNOW

 REFUSED

Now, I’m going to ask you some questions about health conditions or symptoms that you might have experienced. (ASK QUESTIONS FOR EACH HEALTH CONDITION/SYMPTOM BEFORE CONTINUING TO THE NEXT HEALTH CONDITION/SYMPTOM.)

Condition/ Injury	HLTH15. Have you/SUBJECT ever been told by a doctor or other health professional that you/SUBJECT had [FILL SYMPTOM / CONDITION]	HLTH16. What year and month were you/SUBJECT first told by doctor or other health professional that you/SUBJECT had [FILL SYMPTOM / CONDITION]?	HLTH17. Did your/SUBJECT’s [FILL SYMPTOM / CONDITION] change after moving into the FEMA home or did it stay the same? INTERVIEWER: DO NOT READ OPTIONS. MARK “N/A” ONLY FOR CONDITIONS THAT WERE NO LONGER PRESENT WHEN LIVED IN FEMA HOUSING. HLTH18. [If yes]: Did it get better or worse?
Heart burn	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Asthma	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Hay fever	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Sinus problem	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Chronic bronchitis	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Depression, anxiety, emotional problem, or irritability	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse
Other impairment or problem (specify)	 YES  NO	Year _________  JAN  FEB  MAR  APR  MAY  JUN  JUL  AUG  SEP  OCT  NOV  DEC	Did it change?  YES  NO  N/A If changed:  Got better  Got worse

HLTH19. During the past 30 days, how often did (you/SUBJECT) feel ...

(SELECT ONE BOX PER ROW.)

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	DK	RF
So sad that nothing could cheer you up?							
Nervous?							
Restless or fidgety?							
Hopeless?							
That everything was an effort?							
Worthless?							

HLTH20. ASK ONLY IF AT LEAST ONE OF THE ABOVE 6 HLTH24 QUESTIONS IS ANSWERED IN THE POSITIVE FROM ALL OF THE TIME TO SOME OF THE TIME; OTHERWISE SKIP TO HLTH26.

We just talked about a number of feelings (you/SUBJECT) had during the past 30 days. Altogether, how much did these feelings interfere with your life or activities: a lot, some, a little, or not at all?

 A lot

 Some

 A little

 Not at all

 DON’T KNOW

 REFUSED

The next questions are about health insurance. Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide Medical care or help pay medical bills.

HLTH21. (Are you/Is SUBJECT) currently covered by any kind of health insurance or some other kind of health care plan?

INTERVIEWER: IF RESPONDENT ANSWERS BY REPORTING THE TYPE OF HEALTH INSURANCE THEY HAVE, PLEASE CLARIFY THAT A YES/NO RESPONSE IS NEEDED.

 YES → CONTINUE TO HLTH27

 NO → GO TO SMOKE1

 DON’T KNOW → GO TO SMOKE1

 REFUSED → GO TO SMOKE1

HLTH22. What kind of health insurance or health care coverage (do you/docs SUBJECT) have? Please include those that pay for only one type of service (nursing home care, accidents, or dental care). Please exclude private plans that only provide extra cash while hospitalized. Do you have …

(READ OPTIONS. ACCEPT MULTIPLE RESPONSES.)

 Private health insurance

 Medicare

 Medi-Gap

 Medicaid

 SCHIP (CHIP/Children’s Health Insurance Program)

 Military health care (TRICARE/VA/CHAMP-VA)

 Indian Health Service

 State-sponsored health plan

 Other government program

 Single service plan (e.g., dental, vision, prescriptions)

 No coverage of any type

 DON’T KNOW

 REFUSED

SMOKE1. (Have you/has SUBJECT) smoked at least 100 cigarettes in your entire life?

 YES → CONTINUE TO SMOKE2

 NO → GO TO ALC1

 DON’T KNOW → GO TO ALC1

 REFUSED → GO TO ALC1

SMOKE2. How old were you when (you/he/she) first started to smoke cigarettes fairly regularly?

_______ Age (in years)

 Never smoked cigarettes regularly

 DON’T KNOW

 REFUSED

SMOKE3. Do you now smoke cigarettes every day, some days, or not at all?

 Every day

 Some days

 Not at all → GO TO ALC1

 DON’T KNOW → GO TO ALC1

 REFUSED → GO TO ALC1

SMOKE4. On average, how many cigarettes do you now smoke per day?

(1 pack equals 20 cigarettes. If less than 1 per day, enter 1. If 95 or more per day, enter 95.)

_______ Number of number of cigarettes (per day)

 DON’T KNOW

 REFUSED

ALC1. The next questions are about drinking alcoholic beverages. Included are liquor (such as whiskey or gin), beer, wine, wine coolers, and any other type of alcoholic beverage.

In any one year, have you had at least 12 drinks of any type of alcoholic beverage? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or one and half ounces of liquor.

 YES → GO TO ALC3

 NO → CONTINUE TO ALC2

 DON’T KNOW → CONTINUE TO ALC2

 REFUSED → CONTINUE TO ALC2

ALC2. In your entire life, have you had at least 12 drinks of any type of alcoholic beverage?

 YES → CONTINUE TO ALC3

 NO → GO TO C1

 DON’T KNOW → GO TO C1

 REFUSED → GO TO C1

ALC3. In the past 12 months, how often did you drink any type of alcoholic beverage? (If probe is necessary: How many days per week, per month, or per year did you drink? Enter ‘0’ for never.)

______ Quantity

Unit:

 Per week

 Per month

 Per year

 DON’T KNOW

 REFUSED

IF ALC3 IS “0” (I.E., IF RESPONDENT DIDN’T DRINK) → GO TO ALC6

ALC4. In the past 12 months, on those days that you drank alcoholic beverages, on the average, how many drinks did you have? (If less than 1 drink, enter “1.”)

______ Number of drinks

 DON’T KNOW

 REFUSED

ALC5. In the past 12 months, on how many days did you have 5 or more drinks of any alcoholic beverage? (If probe is necessary: How many days per week, per month, or per year did you have 5 or more drinks in a single day? ENTER “0” FOR NONE.)

______ Quantity

Unit:

 Per week

 Per month

 Per year

 DON’T KNOW

 REFUSED

ALC6. Was there ever a time or times in your life when you drank 5 or more drinks of any kind of alcoholic beverage almost every day?

 YES

 NO

 DON’T KNOW

 REFUSED

D12. What health problems related to living in FEMA homes do you think are important for us to study?

___________________________________________________________________________________

C1. How did you first hear about the Katrina Registry? (DO NOT READ OPTIONS.)

 Newspaper

 Flyer

 Website

 Radio

 Relative/friend

 Coworker

 Community Meeting

 Employer

 Phone call

 Letter

 Other (specify) _______________________________

C2. Can you please tell me the name of someone who does not live with (you/SUBJECT) who can always reach (you/SUBJECT)?

First Name__________________ Middle Initial ____ Last Name_________________ Suffix____

IF RESPONDENT REFUSES → GO TO D0

C3. What is this person’s relationship to (you/SUBJECT)?

 Spouse or significant other

 Parent

 Child

 Brother or sister

 Friend

 Other (specify) _______________________________

C4. Where does this person live now?

City__________________State__________________Country_______________________

C5. What are his/her telephone numbers?

Home_______ - _____ - ______

Work ____ - ____ - ____

Cell ____ - ____ - ____

C6. What is his/her email address?

Email ________________________

C7. Could you please tell me the name of another person who does not live with (you/SUBJECT) who can always reach (you/SUBJECT)?

First Name__________________ Middle Initial ____ Last Name_________________ Suffix____

IF RESPONDENT REFUSES → GO TO D0

C8. What is this person’s relationship to (you/SUBJECT)?

 Spouse or significant other

 Parent

 Child

 Brother or sister

 Friend

 Other (specify) _______________________________

C9. Where does this person live now?

City__________________State__________________Country_______________________

C10. What are his/her telephone numbers?

Home_______ - _____ - ______

Work ____ - ____ - ____

Cell ____ - ____ - ____

C11. What is his/her email address?

Email ________________________

C12. And finally, could you please tell me the name of one more person who does not live with (you/SUBJECT) who can always reach (you/SUBJECT)?

First Name__________________ Middle Initial ____ Last Name_________________ Suffix____

IF RESPONDENT REFUSES → GO TO D0

C13. What is this person’s relationship to (you/SUBJECT)?

 Spouse or significant other

 Parent

 Child

 Brother or sister

 Friend

 Other (specify) _______________________________

C14. Where does this person live now?

City__________________State__________________Country_______________________

C15. What are his/her telephone numbers?

Home_______ - _____ - ______

Work ____ - ____ - ____

Cell ____ - ____ - ____

C16. What is his/her email address?

Email ________________________

D0. Finally, I have some questions about you.

D1. (ASK IF NECESSARY.) What is (your/SUBJECT’s) sex?

 Male

 Female

D2. What is (your/SUBJECT’s) date of birth?

Month ___________

Day ___________

Year ___________

D3. (Are you/Is SUBJECT) Hispanic or (Latino/Latina)?

 YES

 NO

 DON’T KNOW

 REFUSED

D4. Which one or more of the following would you say is (your/SUBJECT’s) race? (ACCEPT MULTIPLE RESPONSES.)

 White or Caucasian

 Black/African American

 Asian

 Native Hawaiian/other Pacific Islander

 American Indian or Alaska Native

 No Additional choices

D5. (Are you currently/Is SUBJECT currently) …

 Married

 Divorced

 Widowed

 Separated

 Single, never married

 Living with a partner (boyfriend or girlfriend)

 DON’T KNOW

 REFUSED

D6. What is the highest grade or year of school (you/SUBJECT) completed?

 Less than high school degree

 High school degree (or equivalent)

 Some college

 Bachelor’s degree

 Advanced degree (masters, professional, doctoral degree)

 DON’T KNOW

 REFUSED

D7. Are (you/SUBJECT) currently employed?

 YES → GO TO D8

 NO → GO TO D10

 DON’T KNOW → GO TO D10

 REFUSED → GO TO D10

D8. What is (your/SUBJECT’s) current occupation? (READ LIST. SELECT ONE ONLY. IF RESPONDENT HAS TWO OCCUPATIONS, ASK HIM OR HER TO REPORT THE OCCUPATION IN WHICH THEY WORK THE MOST HOURS.)

 Professional technical, and related occupations

 Executives, administrative and managerial occupations

 Sales occupations

 Administrative support occupations including clerical

 Precision production, craft and repair occupations

 Operatives, except transportation

 Transportation equipment operatives

 Laborers, except farm

 Technical/computer specialists

 Farmers and farm managers

 Financial service

 Other services, except household

 Private household

 DON’T KNOW

 REFUSED

D9. What industry (do you/does SUBJECT) work in?

(READ LIST. SELECT ONE ONLY. IF RESPONDENT WORKS IN TWO INDUSTRIES, ASK HIM OR HER TO REPORT THE INDUSTRY IN WHICH HE OR SHE WORK THE MOST HOURS.)

 Services

 Retail Trade

 Government

 Manufacturing

 Finance, Insurance, and Real Estate

 Wholesale Trade

 Transportation and Public Utilities

 Construction

 Mining

 DON’T KNOW

 REFUSED

D10. What is your best estimate of (your/SUBJECT’s) total income from all sources, before taxes, in the last year?

 Less than $20,000

 $20,000 - $49,999

 $50,000 - $74,999

 $75,000 - $99,999

 $100,000 - $150,000

 More than $150,000

 DON’T KNOW

 REFUSED

D11. What is your best estimate of (your/SUBJECT’s) household’s total income from all sources, before taxes, in the last year? INTERVIEWER: IF NECESSARY, SAY: “Your household’s income includes everyone who lives with you.”

 Less than $20,000

 $20,000 - $49,999

 $50,000 - $74,999

 $75,000 - $99,999

 $100,000 - $150,000

 More than $150,000

 DON’T KNOW

 REFUSED

INTERVIEWER: ASK RESPONDENT FOR THE FOLLOWING INFORMATION FOR D13 – 16.

D13. SUBJECT NAME

First Name__________________ Middle Initial ____ Last Name_________________ Suffix____

D14. Person answering the questionnaire, if other than self [THIS IS IF PERSON ANSWERING FOR CHILD]:

First Name__________________ Middle Initial ____ Last Name_________________ Suffix____

D15. SUBJECT Street Number and Street Name, Apt. No., P.O. Box No.

_________________________________________________________________________________________

City and State Zip Code________

Email Address:

Work Phone ( ) Home Phone ( )___________________

Cell Phone ( )

D16. PROXY Street Number and Street Name, Apt. No., P.O. Box No.

________________________________________________________________________________________

City and State Zip Code________

Email Address:

Work Phone ( ) Home Phone ( )___________________

Cell Phone ( )

D17. Providing part of your Social Security number is totally voluntary.  This information will be kept completely confidential and will only be used to confirm that we have only one interview record for you in our system and in case we need to contact you again in the future. What are the last five digits of (your/SUBJECT’s) Social security number?

__ - __ __ __ __

END CALL