community questionnaire -...

Community Assessment of Freeway Exposure and Health (CAFEH) Study Community Questionnaire

Participant ID: _____________ Interviewer: ______________

Date (month/day/year): __ __ / __ __ / __ __

A. Demographics

A1. In what year were you born? ____________

Don't know 998 Refused 999

A2. How old are you today? _____________ (in years)


A3. What is your sex or gender?

Male 01 Female 02 Transgender 03 Don't know 998 Refused 999

A4. How long have you lived at this street address? _________ years ________ months

[PROBE FOR MONTHS ONLY IF LESS THAN 3 YEARS] Don't know 998 Refused 999

[IF NO PREVIOUS ADDRESS, OR CANNOT REMEMBER ONE IN THE LAST 20 YEARS, GO TO A9]

A5. What is the street address of the home you lived in before this one? Please write down as much as they can remember.

Street Name: __________________________

Street Number: _________________________________

Apt/Unit Number: _________________________________

Town/City: ________________________________________ Zip: ________________________

CAFEH Questionnaire v1-6.15.09 of 33

A6. How many years did you live at that address? __________ years ________ months [PROBE FOR MONTHS ONLY IF LESS THAN 3 YEARS]


[IF DOES NOT HAVE OR CANNOT REMEMBER A SECOND PREVIOUS ADDRESS, GO TO A9]

A7. What is the street address of the home you lived in before that one?

Street Name: ______________________

Street Number: _____________________

Apt/Unit Number: ____________________

Town/City: _________________________ Zip: ______________________________

Don't know 998 Refused 999 N/A (go to A9)

A8. How many years did you live at that address? ___________ years________ months

[PROBE FOR MONTHS ONLY IF LESS THAN 3 YEARS] Don't know 998 Refused 999

A9. What is your race (Mark all that apply)?

White 1 Asian 2 Pacific Islander 3 Black/African-American 4 American Indian or Alaska Native 5 Some other race- print here______________

A10. Are you Latino/Hispanic?

(Mark the no box if you are not Spanish/Hispanic/Latino): Yes 1 No, not Spanish/Hispanic/Latino 2

A11. What do you consider to be your ancestry or ethnic heritage: [GIVE EXAMPLES IF NEEDED; MARK ALL THAT APPLY]

HISPANIC/LATINA:

Puerto Rican 1 Dominican 2 Mexican 3 Cuban 4 Colombian 5 Salvadoran 6 Other Central American (specify): 7 __________________________ Other South American (not Brazil, specify): 8 __________________________ Other Hispanic/Latina (specify): 9 __________________________


ASIAN/PACIFIC ISLANDER:

Chinese 10 Vietnamese 11 Cambodian 12 Asian Indian 13 Korean 14 Filipino 15 Japanese 16 Laotian 17 Pakistani 18 Thai 19 Hawaiian 20 Other Asian/Pacific Islander (specify): 21 _________________________

PORTUGUESE SPEAKING:

Cape Verdean 22 Brazilian 23 Other Portuguese (specify): 24 _________________________

WEST INDIAN/CARIBBEAN ISLANDER:

Haitian 25 Jamaican 26 Barbadian/Bajan 27 Other West Indian/Caribbean 28

Islander (specify):_________________________

AFRICAN/AFRICAN AMERICAN: African-American/ Afro-American 29 Nigerian 30 Other African 31

(specify):________________________________

MIDDLE EASTERN: Lebanese 32 Iranian 33 Israeli 34 Other Middle Eastern (specify): 35 _______________________

AMERICAN ANCESTRY:

White American 36 Native American/ American Indian 37

(specify tribe/affiliation):___________________

EUROPEAN and OTHER ancestries: European (specify): 38

___________________________ Other (specify): 39

___________________________ Don't know 998 Refused 999


A12. Where were you born?

Continental U.S. 1

[IF BORN IN US GO TO QUESTION 14] Mexico 2 Puerto Rico 3 Canada 4 Dominican Republic 5 Cuba 6 Central America 7 South America (other than Brazil) 8 Brazil 9 People’s Republic of China 10

(including Hong Kong) Taiwan 11 Haiti 12 English Caribbean 13

(for example Jamaica, Barbados) Russia 14 Vietnam 15 Cambodia 16 Laos 17 South Korea 18 Japan 19 Europe 20 Cape Verde 21 South Asia 22

(e.g. India, Pakistan, Bangladesh) Africa 23 Other 24

Specify:_____________________ Don’t know 998 Refused 999


A13. In what year did you first start living in the United States (50 states)?

Year ____________


A14. If you have lived outside the US [since you were born or first came here], what is your

best estimate of how many years you have lived in the continental U.S? Include only time lived in the US. Do not include years lived outside the US at any time during your life. Do not include vacations of less than one year.

# of years ______

Have not lived outside the US 997 Don't know 998 Refused 999

A15. Are you now [READ RESPONSES, MARK ONLY ONE]

Working full time 01 Working part time 02 Unemployed, looking for work 03 Unemployed, not looking for work 04 Retired 05 Disabled 06 A homemaker, not looking for work 07 A full-time student, not looking for work 08 Don't know 998 Refused 999

A16. Are you now:

[READ RESPONSES, MARK ONLY ONE]

Married 01 Widowed, living alone 02 Divorced, living alone 03 Separated, living alone 04 Never married, living alone 05 Living with partner 06 Other 07 Don't know 998 Refused 999

A17. How many adults (>18 years of age) live at this address? ________



A18. How many children live at this address? ________


A19. What is the highest grade or year of school you have completed? [CODE ONLY ONE]

Never attended school 0 1st Grade 1 2nd Grade 2 3rd Grade 3 4th Grade 4 5th Grade 5 6th Grade 6 7th Grade 7 8th Grade 8 9th Grade 9 10th Grade 10 11th Grade 11 12th Grade 12 1 Year College 13 2 Years College 14 3 Years College 15 4 Years College 16 1 Year Graduate School 17 2 Year Graduate School 18 3 Year Graduate School 19 4 Year Graduate School 20 Don't know 998 Refused 999

A20. Have you received any of the following diplomas, degrees, certificates, or licenses from

schools you have attended? [CODE ALL MENTIONED.] High School diploma or GED 1 Jr. college degree/associate degree 2 Bachelor's degree 3 Advanced college degree 4

(Masters, Ph.D., LLD, etc.) Vocational/trade school certificate 5

Specify:_________________________ License to practice a trade 6

Specify:_________________________ Other degree, license, etc. 7

Specify:_________________________


B. Time-Activity The following section seeks to learn about where you spend time during workdays and non-work days and about how you travel from place to place.

Please think about your most recent school/workday from midnight to midnight and choose the main location in which you spent each one-hour time block. If you were traveling during this period, please indicate when you were a driver or passenger on a highway and how long you were traveling on a highway, to the best that you can recall. If you do not work, report a weekday.

[ASK HOUR BY HOUR WHICH MICRO-ENVIRONMENT THE RESPONDENT SPENT TIME IN.] [IF THEY SPENT TIME AS A DRIVER OR PASSENGER ON A HIGHWAY, PLEASE INDICATE HOW MANY MINUTES IN THE “TIME ON HIGHWAY” COLUMN ON THE RIGHT-HAND SIDE.] [BY “OUTSIDE AT HOME” WE MEAN OUTDOORS WITHIN ONE BLOCK OF THE RESPONDENT’S RESIDENCE.] [BY “HIGHWAY” WE MEAN HIGH TRAFFIC, HIGH SPEED ROADWAYS. EXAMPLES INCLUDE: I-93, I-95, I-90, I-495, RT. 2, RT. 3, RT. 9, RT. 16, RT. 24, STORROW DR., MCGRATH HWY, SUMNER TUNNEL, AND OTHER SIMILAR ROADWAYS. WE DO NOT MEAN LIGHTLY TRAVELED RURAL ROADWAYS OR BUSY URBAN STREETS.]

Work Day Home (Inside)

Home (Outside)

School/Work Other: Inc. non-hwy travel

Time On Highway

12 -1 AM 1-2 AM 2-3 AM 3-4 AM 4-5 AM 5-6 AM 6-7 AM 7-8 AM 8-9 AM 9-10 AM 10-11 AM 11 AM-12 PM 12-1 PM 1-2 PM 2-3 PM 3-4 PM 4-5 PM 5-6 PM 6-7 PM 7-8 PM 8-9 PM 9-10 PM 10-11 PM 11-12 AM



B1. Was the day reported above typical in terms of time spent on highways? Yes 1 No 0 Don't know 998 Refused 999

B2. On an average work day, how many hours each day do you spend doing the following during

your travel time to and from work?

Walking or biking ____ hrs ____ minutes 01 In a private car or taxi ____ hrs ____ minutes 02 On a bus ____ hrs ____ minutes 03 On a subway or trolley ____ hrs ____ minutes 04 On a commuter train ____ hrs ____ minutes 05 Other ____ hrs ____ minutes 06 (Specify): __________________________



Now please think about your most recent non-school/work day and choose the main location in which you spent each time block. If you were traveling during this period, please indicate when you were a driver or passenger on a highway and how long you were traveling on a highway. Please indicate how many minutes in the “Time on Highway” column. If you do not work, report a weekend day.

[FLIP A COIN TO CHOOSE EITHER SATURDAY OR SUNDAY IF THESE WERE THE MOST RECENT NON-WORK DAY. FOR OTHER DAYS USE THE MOST RECENT NON-WORK DAY] [ASK HOUR BY HOUR WHICH MICRO-ENVIRONMENT THE RESPONDENT SPENT TIME IN. FOR EACH TIME PERIOD IF YOU SPENT TIME AS A DRIVER OR PASSENGER ON THE HIGHWAY DURING THAT HOUR, PLEASE INDICATE HOW MANY MINUTES IN THE “TIME ON HIGHWAY” COLUMN ON THE RIGHT-HAND SIDE.]

[BY “OUTSIDE AT HOME” WE MEAN OUTDOORS WITHIN ONE BLOCK OF THE RESPONDENT’S RESIDENCE.] [BY “HIGHWAY” WE MEAN HIGH TRAFFIC, HIGH SPEED ROADWAYS. EXAMPLES INCLUDE: I-93, I-95, I-90, I-495, RT. 2, RT. 3, RT. 9, RT. 16, RT. 24, STORROW DR., MCGRATH HWY, SUMNER TUNNEL, AND OTHER SIMILAR ROADWAYS. WE DO NOT MEAN LIGHTLY TRAVELED RURAL ROADWAYS OR BUSY URBAN STREETS.]

Non-Work Day Home (Inside)

Home (Outside)

School/Work Other: Inc. non-hwy travel

Time On Highway

12 -1 AM 1-2 AM 2-3 AM 3-4 AM 4-5 AM 5-6 AM 6-7 AM 7-8 AM 8-9 AM 9-10 AM 10-11 AM 11 AM-12 PM 12-1 PM 1-2 PM 2-3 PM 3-4 PM 4-5 PM 5-6 PM 6-7 PM 7-8 PM 8-9 PM 9-10 PM 10-11 PM 11-12 AM



B3. Was the day reported above typical in terms of time spent on highways? Yes

Yes 1 No 0 Don't know 998 Refused 999

B4. How much time do you spend on the following modes of transportation on an average non-

work day?

Walking or biking ____ hrs ____ minutes 01 In a private car or taxi ____ hrs ____ minutes 02 On a bus ____ hrs ____ minutes 03 On a subway ____ hrs ____ minutes 04 On a commuter train ____ hrs ____ minutes 05 Other ____ hrs ____ minutes 06 (Specify): ______________________


B5. Do you usually spend 2 hours or more per day or 10 hours or more per week at any of these

outdoor locations in your neighborhood [MARK ALL THAT APPLY]?

Foss Park time of day: morning afternoon evening night Bay Boat House time of day: morning afternoon evening night Grimmons Park time of day: morning afternoon evening night Harris Park time of day: morning afternoon evening night Riverfront at Assembly Sq. time of day: morning afternoon evening night Draw Seven Park time of day: morning afternoon evening night Healy School Playground time of day: morning afternoon evening night Other time of day: morning afternoon evening night Specify: ______________________________________

B6. In an average week, how many hours do you usually spend walking, running, biking, etc

within 200 meters/yards of a highway? [100 METERS/YARDS IS ABOUT ONE SPORT FIELD OR 1/8 OF A MILE; IF YOU NEED TO CLARIFY “HIGHWAY” REFER BACK TO DESCRIPTION ABOVE]

None 01 1 hour or less 02 2 -3 hours 03 4-5 hours 04 More than 5 hours 05

B7. What traffic condition best describes the majority of your time traveling by motor vehicle

during the day? Light traffic, 01 Heavy traffic, 02 Congested/stop-and-go 03 N/A (Includes zero time in motor vehicle) 04 Don't know 998


Refused 999 C. Household Exposure/ Indoor Air [ALL OF THE QUESTIONS IN THIS SECTION APPLY TO THE ADDRESS AT WHICH THE REPSONDENT LIVES]

C1. How often do you open windows during December to February? Never 01 Skip to C4 Fewer than 2 days a week, 02 2-5 days a week, 03 6-7 days a week 04 Don't know 998 Refused 999

C2. On those days, how many windows did you usually have open? ______


C3. On average, how open were your windows on those days that they were open?

Cracked open 01 Part way open 02 Wide open 03 Don't know 998 Refused 999

C4. How often do you open windows during June to August?

Never 01 Skip to C7 Fewer than 2 days a week 02 2-5 days a week 03 6-7 days a week 04 Don't know 998 Refused 999

C5. On those days, how many windows did you usually have open? ______


C6. On average, how open were your windows on those days that they were open?

Cracked open 01 Part way open 02 Wide open 03 Don't know 998 Refused 999

C7. Is there a vent or fan in the bathroom that vents to the outdoors?



C8. Is there a vent or fan for the stove that vents to the outside? Yes 1 No 0 Don't know 998 Refused 999

C9. How many rooms are there not counting the bathroom or the hallway?

1-2 01 3-4 02 5-7 03 8-10 04 11 or more 05 Don't know 998 Refused 999

C10. Is an air conditioner used in your house?

Yes 1 No 0 GO TO QUESTION # C13 Don't know 998 GO TO QUESTION # C13 Refused 999 GO TO QUESTION # C13

C11. If yes: how many days did you use the air conditioner last summer?

< 10 days 01 11-30 days 02 Most days for 1-2 months 03 Most days for >2 months 04 Don't know 998 Refused 999

C12. If yes: what type of air conditioner do you have?

Central A/C 01 Window Units: how many? _______ 02 Other (specify): ________________ 03 Don't know 998 Refused 999

C13. Which of the following were used to heat this house in the past year:

[MARK ALL THAT APPLY] Radiator or baseboard with hot water, 01

steam or electric heat Forced air (vents) 02 Electric space heater 03 Gas space heater 04 Kerosene space heater 05 Wood burning stove 06 Fireplace 07 Oven/stove (other than for cooking) 08 Other, please specify ________ 09 Don't know 998 Refused 999


C14. What is the energy source for producing heat for this house? Electric 01 Natural gas 02 Oil 03 Other (please specify____________) 04 Don't know 998 Refused 999

C15. If you have a boiler, is it located in the:

Living space of your house 01 Basement 02 A closet or other separated area 03 On another floor (other than basement) 04 Other 05 Do not have a boiler 06 Don’t know 998 Refused 999

C16. How often do you or does someone else cook in your residence?

Never 01 A few days a month 02 More than half of the days of the month, 03

but less than daily Almost daily 04 Other, please specify: 05

_____________________________


D. Smoking

D1. Do you smoke tobacco currently? Yes GO TO D3 1 No 0 Don't know 998 Refused 999

If yes:

Cigarettes Cigars Pipe/Hooka/other Age first began smoking

Packs/Day currently

How many years have you smoked, excluding any years that you stopped?

D2. If you do not smoke now, have you ever smoked?


If yes:

Cigarettes Cigars Pipe/Hooka/other Age began smoking

Packs/Day

How many years have you smoked, excluding any years that you stopped?

Age quit finally

D3. How often do people, including residents and guests, smoke in your home?

5-7 days per week 01 3-4 days per week 02 1-2 days per week 03 0 days per week 04 Don't know 998 Refused 999

D4. How many people living in your home (other than yourself) smoke? ______



D5. On average, how many hours a day are you exposed to cigarette smoke of others: At home ______ hours ______ min 01 At work ______ hours ______ min 02 In other areas ______ hours ______ min 03


D6. How often are you in a car with someone who smokes?:

More than 5 times/ week 01 1-4 times/ week 02 1-2 times/ month 03 Never or almost never 04 Don't know 998 Refused 999


E. Sound

E1. How much does sound from traffic bother you currently when you are at this address? Never 01 Sometimes 02 Often 03 Always 04 Don't know 998 Refused 999

E2. In the past five years, has sound from traffic bothered you more, less or about the same as

before then? More 01 Less 02 About the same 03 Don't know 998 Refused 999

E3. Are there other sounds that regularly bother you when you are at this address? [CHECK ALL

THAT APPLY]: Street traffic 01 Jets, airplanes, helicopters 02 Trains 03 Emergency vehicle sirens 04 Loud music 05 Car alarms 06 Other ___________________________ 07 Don't know 998 Refused 999

E4. Is this house or apartment

Owned by you or someone 01 in this household

Rented (not subsidized, not public) 02 Subsidized 03 Public Housing 04 Don't know 998 Refused 999

E5. About when was this building first built? If not sure ask other household members [ENTER

ONE] 1995 to present 01 1975 to 1994 02 1950 to 1975 03 1900 to 1949 04 Before 1900 05 Don't know 998 Refused 999


F. Occupational Exposure

F1. Please describe your tasks at work: PROBE FOR DESCRIPTIONS OF TASKS. EXAMPLES INCLUDE: OFFICE WORK DRIVING A TRUCK OR TAXI JANITORIAL WORK COOKING (RESTAURANT) WELDING REPAIRING CARS TEACHING RETAIL SERVICE PUMPING GAS RESPONDING TO EMERGENCIES/FIRES

Current Tasks Job #1 Years @ job

Street, City, Zip of site of work (N/A if not usually a set location)






Previous Tasks Job #1 Years @ job






F2. Have you ever been regularly exposed to any of the following? If "yes," indicate the number of years exposed [MARK ALL THAT APPLY]:

Asbestos ____ yrs 01 Acids/solvents/other

industrial chemicals ____ yrs 02 Coal or stone dusts ____ yrs 03 Textile fibers/dusts ____ yrs 04 Wood dust ____ yrs 05 Other dusts,

Specify: _____________ ____ yrs 06 None of these 07 Don't know 998 Refused 999

F3. How often are you exposed to motor vehicle exhaust, including heavy street or highway

traffic, at your current job(s)? Daily multiple hours per day 01 Daily for less than an hour 02 Once per week 03 Once per month 04 Never 05 Not employed currently 06 Don't know 998 Refused 999

F4. How often, in your most recent job prior to your current job, were you exposed to motor

vehicle exhaust at work? Daily for multiple hours per day 01 Daily for less than an hour 02 Once per week 03 Once per month 04 Never or almost never 05 Don't know 998 Refused 999

F5. How often does your current job require substantial physical exertion?

Never 01 Rarely 02 Occasionally 03 Almost always 04 Don't know 998 Refused 999


G. Diet

These questions are about the different kinds of foods you ate or drank during the PAST MONTH, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

G1. During the past month, how often did you eat HOT OR COLD BREAKFAST CEREALS?

Include cereals eaten at any time of the day.

Less than 1 times per week 01 1-6 times per week 02 7-14 times per week 03 15 or more times per week 04 Don't know 998 Refused 999

G2. Which kinds of cereal did you usually eat?

Cooked cereals (such as oatmeal,

cream of wheat, grits) 01 All bran cereals (such as All Bran,

Fiber One, 100% Bran, or Bran Buds) 02 Cereals with some bran or fiber (such as

Cheerios, Raisin Bran, Shredded Wheat, Total, Wheaties, 40% Bran flakes, Granola, Grape Nuts, Muselix, etc.) 03

Cereals with little bran or fiber (such as Corn Flakes, Honey Nut Cheerios, Froot Loops, Rice Krispies, Kix, Frosted Flakes, Special K, Cap'n Crunch, Blueberry Morning, Product 19, etc.) 04

Other 05 Don’t eat cereal 06 Don't know 998 Refused 999

G3. During the past month how often did you eat WHOLE GRAIN BREAD including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel.

Do NOT include white bread. INCLUDE cracked wheat, multi-grain and bran breads.



G.4 How often did you have WHOLE, 2% or 1% MILK, either to drink or on cereal? Include a cup of milk with coffee flavor added, but DO NOT include small amounts of milk in coffee or tea. Also, include yogurt, unless it is non-fat.

DO NOT include cream or soy milk . INCLUDE buttermilk, and lactose-free milk. Also INCLUDE chocolate or other flavored milks.


G5. During the past month how often did you eat FRIED FOOD such as FRENCH FRIES, home fries, potato chips, tostones, Pupusas, FRIED CHICKEN or hash brown potatoes?


G6. During the past month how often did you eat RED MEAT? Do NOT include lean or extra lean red meat.


G.7. During the past month how often did you eat food that was cooked in oil, had added butter or had salad dressing added? Do NOT include use of olive oil or canola oil or vegetable oil.



G8. During the past month how often did you eat oily fish (tuna, salmon, swordfish, etc.).

Less than 1 times per week 01 1-2 times per week 02 3-6 times per week 03 7-14 times per week 03 15 or more times per week 04 Don't know 998 Refused 999

G9. During the past month, how often did you drink regular, carbonated SODA OR SOFT DRINKS or FRUIT-FLAVORED DRINKS (such as Kool-aid, Hi-C, lemonade, or cranberry cocktail) that contain sugar?

Do NOT include diet soda or diet or sugar-free fruit drinks. Do NOT include juices or tea in cans. DO NOT include diet mineral water or diet flavored waters.


G10. During the past month, How often did you drink 100% FRUIT JUICE, such as orange, mango, apple, and grape juices? Do NOT count fruit drinks.

INCLUDE only 100% pure juices. Do NOT include fruit drinks with added sugar, like Kool-aid, Hi-C, lemonade, cranberry cocktail, Gatorade, Tampico, and Sunny Delight.


G11. During the past month how often did you eat FRUIT? COUNT fresh, frozen, or canned fruit. Do NOT count juices.

Include fruits such as apples, bananas, applesauce, melon, berries, fruit salad, mangos, papayas, oranges, and grapes.



G12. During the past month, how often did you eat non-starchy VEGETABLES?

Include leafy greens, lettuce, SALAD, root vegetables (carrots, beets), spinach, bok choy, tomatoes, broccoli, kale, cabbage, egg plant, sweet peppers, cucumber, squash, green beans, peas, bitter melon, cauliflower, etc.


G13. During the past month how often did you eat WHITE POTATOES, other starchy vegetables such as Yucca, plantains or WHITE RICE, TORTILLAS, or WHITE BREAD? Do not include fried foods.

Do NOT include yams or sweet potatoes. INCLUDE red-skinned and Yukon Gold potatoes.


G14. During the past month how often did you eat COOKED BEANS, such as refried beans, baked beans, bean soup, and pork and beans? Do NOT include green beans.


G15. During the past month how often did you eat COOKIES, CAKE, PIE, ICE CREAM or BROWNIES; DOUGHNUTS, sweet rolls, danishes, muffins, pop-tarts, snack cakes?

EXCLUDE low-fat kinds.



G16. During the past month how often did you eat any kind of CHEESE? Include cheese as a snack, cheese on burgers, sandwiches, or pizza, and cheese mixed into such foods as lasagna, enchiladas or casseroles.

INCLUDE cream cheese.


G17. During the past month how often did you eat EGGS? Include eggs in quiche, omelets, custard, flan, etc.



H. Physical Activity

The next questions are about physical activities.

H1. How many times per week do you do VIGOROUS leisure-time physical activities for AT LEAST 10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or heart rate?

________ times per week for vigorous leisure-time physical activities.

Never 0 Skip to H3 Unable to do this type of activity 996

H2. About how long do you do these vigorous leisure-time physical activities each time?

[ENTER NUMBER OF MINUTES OF VIGOROUS LEISURE-TIME PHYSICAL ACTIVITIES.]

___________ Minutes

Don’t know 998 Refused 999

H3. How many times per week do you do LIGHT OR MODERATE LEISURE-TIME physical

activities for AT LEAST 10 MINUTES that cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or heart rate?

________ times per week for light or moderate leisure-time physical activities.


H4. About how many minutes do you do these light or moderate leisure-time physical activities

each time?

[ENTER NUMBER FOR LENGTH OF LIGHT OR MODERATE LEISURE-TIME PHYSICAL ACTIVITIES.] ___________ Minutes



H5. Which one of the following BEST describes your usual daily activities related to moving around? Do NOT include exercises, sports, or physically active hobbies done in your leisure time. Pick the one you do MOST often

[IF RESPONDENT IS BEDRIDDEN, ENTER '1']

SIT during MOST of the day 01 STAND during MOST of the day 02 WALK AROUND MOST of the day 03 Don’t know 998 Refused 999

H6. Which one of the following BEST describes your usual daily activities related to lifting or

carrying things? INCLUDE activities done in your leisure time. Pick the one you do MOST often.

NOT lift or carry things very often 01 LIFT or carry LIGHT loads 02 LIFT or carry MODERATE loads 03 LIFT or carry HEAVY loads 04 Unable to lift or carry loads 05 Other 06 Don’t know 998 Refused 999

H7. How much sleep do you usually get at night on weekdays or workdays? ______ ENTER HOURS (HOURS MUST BE BETWEEN 0-24)



I. Stress

Instructions: The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with a check how often you felt or thought a certain way.

I1. In the last month, how often have you felt that you were unable to control the important things in your life?

Never 0 Almost never 1 Sometimes 2 Fairly often 3 Very often 4

I2. In the last month, how often have you felt confident about your ability to handle your personal problems?


I3. In the last month, how often have you felt that things were going your way?


I4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?



J. Health Status

J1. Has your doctor ever told you that you had congestive heart failure? Yes 1 No (SKIP NEXT QUESTION) 0

J2. When were you first told this?

Within the past 12 months; 01 1-4 yrs ago; 02 5-9 yrs ago; 03 10-20 yrs ago; 04 Greater than 20 yrs ago 05

J3. Has your doctor ever told you that you had a heart attack (also called myocardial infarction)

or coronary heart disease? Yes 1 No (SKIP NEXT QUESTION) 0



J5. Has your doctor ever told you that you had angina pectoris (severe chest pain)?

Yes 1 No (SKIP NEXT QUESTION) 0



J7. Has a doctor or nurse ever told you that you have diabetes or high blood sugar?




J9. Has a doctor or nurse ever told you that you had high blood pressure or hypertension?



J10. When were you first told this? Within the past 12 months; 01 1-4 yrs ago; 02 5-9 yrs ago; 03 10-20 yrs ago; 04 Greater than 20 yrs ago 05

J11. Has a doctor or nurse ever told you that you had high bad cholesterol (LDL)?


J12. When were you first told that you had high cholesterol?


J13. Has your doctor ever told you that you had rheumatoid arthritis?




J15. Has a doctor ever told you that you had asthma?




J17. Has your doctor ever told you that you had a stroke?


J18. Was this stroke during the



K. Medications ASK THE RESPONDENT TO SHOW YOU BOTH PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS THAT THEY ARE CURRENTLY TAKING. RECORD THE NAME OF THE MEDICATION, DOSE AND FREQUENCY DIRECTLY FROM THE MEDICATION CONTAINER. ASK THE RESPONDENT TO TELL YOU HOW LONG THEY HAVE BEEN TAKING EACH MEDICATION.

Name of Medication Dosage Frequency How many years have you been taking this medication? [USE <1 FOR LESS THAN ONE YEAR]

Prescription:

Non-Prescription:


L. Risk perception Now I’m going to read some general statements about society and politics, and, for each statement, I want you to tell me if you agree strongly, agree somewhat, neither agree or disagree, disagree somewhat, or disagree strongly. You might feel that you would agree with a statement in some situations and not in others, but that’s okay – just say how you feel about it in most situations, or in general. There are no right or wrong answers, we just want your opinion. Are you ready?

Agree Strongly

Agree Somewhat

Neither Agree nor Disagree

Disagree Somewhat

Disagree Strongly

Refused

Government should redistribute income from people who are better off to those who are less well off.

1

2

3

4

5

999

On the whole, government officials try to do what is best for the public.

1

2

3

4

5

999

One of the problems with people today is that they challenge authority too often

1

2

3

4

5

999

There are times when people should follow their consciences even if it means breaking the law

1

2

3

4

5

999

Private enterprise needs to be controlled to protect everyone’s needs

1

2

3

4

5

999

All societies have inequalities which it is better not to interfere with

1

2

3

4

5

999

People should put their families and communities ahead of their own interests.

1

2

3

4

5

999

People with money should be left to enjoy it.

1 2 3 4 5 999

If people are better off, it is usually because they have earned it.

1 2 3 4 5 999


The next set of questions is about your health and how much you feel you can do about it. Again, I’ll read each statement and you tell me whether you agree strongly, agree somewhat, neither agree nor disagree, disagree somewhat, or disagree strongly. Again, you might think it depends on the situation, but just think about this in general or in most situations. Are you ready?

Agree Strongly

Agree Somewhat

Neither Agree nor Disagree

Disagree Somewhat

Disagree Strongly

Refused

If I become sick, I have the power to make myself well again.

1

2

3

4

5 999

Often I feel that I have no control over whether or not I will get sick.

1

2

3

4

5 999

It seems that my health is greatly influenced by accidental happenings.

1

2

3

4

5 999

I am directly responsible for my health

1

2

3

4

5 999

Whatever goes wrong with my health is my own fault.

1

2

3

4

5 999

When I stay healthy, I am just plain lucky.

1

2

3

4

5 999

When I feel ill, I know it is because I have not been taking care of myself properly.

1

2

3

4

5 999

Now I’ll ask you some questions about air pollution specifically affecting the neighborhood where you live.

L1. With regard to air pollution in your neighborhood how much have you learned from TV, radio, newspapers, community meetings, or any other source?

A lot 01 Some 02 Very little 03 None at all 04 Don't know 998 Refused 999

L2. How harmful do you believe that air pollution in this neighborhood is to you or to others who

live here?

Very harmful 01 Somewhat harmful 02 Slightly harmful 03 Not at all harmful 04 Don't know 998 Refused 999


L3. How harmful do you believe that air pollution specifically coming from the highway is to you or other people who live nearby?

Very harmful 01 Somewhat harmful 02 Slightly harmful 03 Not at all harmful 04 Don't know 998 Refused 999

L4. In your opinion, should the government do more to protect people in your neighborhood from

air pollution, is the government regulating too much already, or is current policy about right?

Should do more 01 About right 02 Doing too much 03 Don't know 998 Refused 999


M. Income [ASK THE RESPONDENT TO ANSWER ONE OF THE FOLLOWING QUESTIONS ABOUT INCOME, WHICHEVER THEY FEEL IS EASIEST FOR THEM] M1. Approximately what is the gross annual income for all family members in this household (before taxes)?

Less than $16,500/year 01 $16,500-24,999 02 $25,000-49,999 03 $50,000-74,999 04 $75,000-99,999 05 $100,000 or more 06 Don't know 998 Refuse 999

OR

M2. What is the total income received last month, (LAST CALENDAR MONTH & CURRENT CALENDAR YEAR) by all family members in this household before taxes?

Less than $500/month 01 $500-1500 02 $1501-2500 03 $2501-4000 04 $4001-6000 05 More than $6000 06 Don't know 998 Refuse 999

M3. What is your present religion, if any? Are you:

Protestant 01 Roman Catholic 02 Mormon 03 Orthodox such as Greek or Russian Orthodox 04 Jewish 05 Muslim 06 Buddhist 07 Hindu 08 Atheist 09 Agnostic 10 Something else 11

(Please list):_________________ Don't know 998 Refuse 999


community questionnaire -...

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