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Appendix A: Basic Standard Environmental Inventory Questionnaires Source: Lebowitz et al., 1989b. 311

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312 ASSESSING HUMAN EXPOSURE Basic Standard Environmental Inventory Questionnaire. Wok Hooded Cheract~ke Name of designated head of household: Name of Respondent Home phone: Zip code: Date: This is a questionnaire for you to complete, regarding your present living quarters. Most of the questions aslred are about the materials, appliances and furniture that are used within your home. To record your reaponae(a) circle ( ), checl: 1 ] or write In the reaponaea to each question. Please follow the arrows pointing to the aide questions inside of looses. For moat of the questions in bold print, a "no' response will instruct you to "slcip to" the nest bold printed question. You can reach us at or if you have any questions.' We appreciate your asaiatance in this study. Your aruvrer' will be Icept confidential ant unit for research pun poses only. Thinly you for your cooperation. Id~Core lUlodule For" Pad Standard E.l.a. Location Dab State County (2)l Census tract Bloclc # (5,5) Street address: ,' (20) Apt [space # B7. City, zip a/ (20,5-5) Zip code Name of reapontent (2) B. Housing amraderl~ Thelte questions are to determine the type of housing unit ant living quarters in which your household lives. Circle one number only for each question. Hal a:. }'~n-~:.'t/~.~/P9. In.tru~ no refer t. r`,rm~ta wh ch are fecund ~ n th, `,ri`~ine! qv - ~tionnairc Further nears t nit I... the I:n`'t~'nm~ntel Invent ret Qu~tionnsir. are available (rom the au h..r~ a; ~ n ~-Roth nd ~ ale retold lengths 1416 B1. How many rooms do you have in your living quarters? (Do not count bathrooms, porches, balconies, foyers. halls, or half-roome.) Please Circle: 1 2 3 4 5 6 7 8 9+ (1) B2. Are your living quarters 1. Owned? 2. Rented? 3. Other? B3. Which bat describes this building? (Include all apartments, flats, etc., even if vacant.) 1. A mobile home or trailer 2. A one-family house detached Tom any other house 3. A one-family house attached to one or more homes 4. A building for 2 families 5. A building for 3 or 4 families 6. A building for 5 to 9 families 7. A building for 10 to 19 families 8. A building for 20 or more families 9. A boat, tent, varl, etc. 10. Other, please specify: (1) (1) B4. How many stories (floors) are in this building? (Count an attic or basement as a story if it has any finished rooms for living purposed) 1. lto3 3. 7tol2 2. 4 to 6 4. 13 or more stories (1 B5. About when was this building originally built? (Circle when the building eras first constructed, not when it was remodeled, added to, or converted.) 1. 1986 to present 4. 1960 to 1969 7. 1939 or earlier 2. 1980 to 1985 5. 1950 to 1959 9. Don't Know 3. 1970 to 1979 C. 1940 to 1949 (1) Be. When did your household/family move into this house (or apartment)? 1. 1986 to present 4. 1960to 1969 2. 1980 to 1985 5. 1950 to 1969 3. 1970 to 1979 6. 1940 to 1949 7. 1939 or earlier (1) How many bedrooms to you have? (Count room used mainly for sleeping even if used also for other purposes.) O. No bedroom 2. 2betrooms 4. 4 bedrooms 1. 1 bedroom 3. 3 bedrooms 5. 5 or more betrooms(1) B8. Where are cars/vehicles Dually parlcet near your living quarters? (Circle all that apply) 1. In an underground garage 2. In an attached garage 3. In an attached carport 4. On the street next to living quarters 5. Other (Specify): (1) C. Occupant Cl~ared~tica The following questions describe the members of the household. JAPCA

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APPENDIX A 313 (b) Is your clothes dryer gas or electric? 1. Gas 3. Don't Rev 2. Electric (c) Where u the dot}~ee dryer located? (1) 1. In a room within the living quarters, such as the kitchen. 2. In a closet or storage room in part of the main living quarters 3. In a utility or closet room separate from the main living quarters. 4. In the garage. 5. In the basement. (1) 6. Outside. (d) 1e the dryer vented? 1. Yes, always outside. 2. Yes, with an insite/outaide e~ntch. 3. Not vented to outside. `1. Don't tDOW. Ed. Heath System (1) (a) What is the STUD type of fuel used to beat your living (d) quarters? (circle the one most often used) 1. Gas 6. Woot 2. Electric 7. Solar 3. Fuel oil 8. None-Skip to # E5 d. Kerosene 9. Other (Specify) 5. Coal tl) (b) What is the main type of furnace or heating system used to heat your living quarters? (circle one) 1. Forced air (central system with ducts that blow air into most rooms) 2. Wall furnace 3. Steam 4. Hot crater 5. Floor furnace 6. Gravity furnace ?. Portable heater 8. Other (specify ) (1) 9. None E5. Unvented Space Heaters (a) During the cold weather, do you use portable KERO SE}JE heaters in your living quarters? 1. Yes-Hoer may? 2. No-slip to $E5(c) (2) (b) How often do you use your KEROSENE heater during the colt weather? 1. Three or more days per weelc 2. One or two days per weel: 3. Only in the morning to talce the chill off (for le" than one hour) (1) (c) Do you use any ~aJ] GAS heaters ire your living quart ters? 1. Yes-How many? 2. No -slcip to # E6 (2) (d) How often do you use your GAS heater during the cold weather? 1. Thm or more days per weals 2. One or more days per week 3. Only in the morning to take the chill off (for less than one hour) 1418 (e) Is the flame terrible? 1. Yee 2. No E6. Woot Stove and/or Firephee (1) (a) Dig the cold weather,do you use swoop burning stove to help heat your living quarters? 1. Yes-How many? 2. No-elrip to #E6(c) (1) (b) How often do you use a wood burring stove during the cold weather? 1. Three or more days per Reels 2. One or two days per weel; 3. Only iD the morning to talce the chill off (for le" than one hour) (1) }fig the cold weather, do you use any fireplaces your }icing quarter'? 1. Yes ~ How runny? (2) 2. No-altipto#F How often do you use your fireplaces during the cold weat'Der? 1. Three or more days per weelc 2. One or two days per wells 3. Only in the morning to talce the chill off (for le" than one hour) F. Radon (1) F1. Do you get water for general household use from a city or public system, a private well, or some other source? 1. city or public water system 2. private well supplying I or more homes 3. some other source (1) Specify I (1) F2. What months of the year are the living quarter' closed come pletely because of heating or air conditioning? (ANSWER FOR BOTH HEATING AND AIR CONDITIONING) 1. none of the year (88) 2. all of the year (20) 3. part of the year-circle months below JAN FEB MAR APR MAY JUN 01 02 03 04 05 06 JUL AUG SEP OCT NOV 07 08 09 10 11 DEC (2) 12 F3. Is there a crawl space or open space under any part of your living quarters? (Note: This is a space between the ground and the floor that cannot be occupied; it is not a basement or cellar.) 1. Yes 2. No (1) F4. Is any part of the foundation or loiterer aralls of your building built of concrete bloclm or cinder blocks? 1. Yes 2. No (1) F5. r)o you have a full or partial Cement, a cellar, or a level of the builder for which one or more aralle are completely or partial ly below the ground? I. Yes 2. No (1; JAPCA

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314 ASSESSING HUMAN EXPOSURE C'1. Number in household la ) How man) children under age 18 are there lit ing in the He uphold? Number of Children ~ 2' (b) How many adults ages 18 and older. are there living in the Household? Number ages 18~61 ~'3 Number age 62 or more ( 2 For the Ill - motet - let of the household (Please identify one person as the head and answer the f`'l. lowing questions for this individual) C2. What ethnic group (race) does this person consider themxl!~? (circle one only) 1. Whim Non Hispanic 2. Hispanic 3. Black 4 Sian 5. Other (specify): ( I ) C3a. What is the highest grade (or year) of regular scherzi this peteson has ever attended? (For exer~tple completion of high school ~ 12) Highest grade attended (2) C4a. Doca heiahe have a paid job out of the home? 1. No self employed in the home 2. No. full time homemaker 3. Yes. worlring full time 4. Yes. working part time 5. No. out of work just now but. tHually employed 6. No. a full~time student 7. Other (specify): (I) C4b. Occupattion I I checle here if this person has never worked outside f the home. and skip to nest quat.ion. 1. What id or was hi/her uncial occupation? (:3) (c) 2. What jB higher job title?: _ For the resDo'ndetst (if not the Head Or Household) ( .S. What ethnic group (race) d<, you consider yourself? (circle `'ne <,nly) 1. White. N`'n Hispanic 2. H ispanic :~. Black 4. Asian '. Other. Ispecify: ) ( ~ ) ( tea ~ hat is the highest tirade (fir ~ear) <,f regular sch`M,I that yells hand ever attended ? I F`'r example. `~,mpleti`,n `,f high school - 1 2) Highest grade atler~ded / 2, . ~ 1) .~`,t ,t the h.,me ' I No elf t mpl~yed in the helms N... foil time h~.mem;~ker :` I'm. irking lull time `m`~,rkiritc ',art tints N I~t ,r v.~,rk just a,.; tilt Ally eml~l yt. N`, - Skip t`, # } :1 :2. How many cigarettes. pipefuls. and/~'r cigars were sm`>ked IN Y OttR LlY IN(. Ql.7AR I ERIC (e) During the motet recent ~ Ellis DAY: ~ cigarettes # pipes and/~,r cigars (b\ During the most receipt U El:};~} Nl) DAY: # cigarettes # pipes And/~,r <.iKars E. Cooking and Other Appllu~ce US El. Cooking (a) Do you have a gas range `,r `,ven 1. Yes - continue below 2. N<' skip to, # F:2 (1) (Jo t5) (1) (b) Does your (;At; range <,r oven have a c`'ntinu`'u:`ly tours ink pillar light? i. Yes 2. N.. (I) During the winter d`, you even use the retake fir At n t.. help heat the living quarters? 1. Yes. three fir m`,re days per week 2. Yes tine fir tw`, days leer week :~. Yes <,nly in the m<,rning 1., take the ~ hill Al (less than .,ne hour) 4. N`' E2. Water Heater (a) Is there a (;At; water heater in your living quarters' 1. Yes - continue bel`,w # 1~:2~1 2. N.' - ski;' t ~ Questi',,1 # 1~` Where is your water heater I`~ kill I., = 1: ~ 1417

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315 ~- ~- ~- . . ~- ~ ~ I_. o o ~ o ~ 8 ~ ~= g . e., ~C ~ ~ ~ "C: ~ ~ o O 0 3 ~3~ ~o 3 ~ [3 ~ bO tD ~ c~ @ ~ ~ `,., ~ ~ - v' c, . . . ~ ~ cc

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