National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
1
Appendix
1
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke
2003
Questionnaire
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
2
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke
Questionnaire
PAPERWORK
REDUCTION
ACT
OF
1995
Public
reporting
for
this
collection
of
information
is
estimated
to
average
.25
hours
per
response,
including
the
time
for
reviewing
instructions,
searching
existing
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.
The
current
OMB
control
number
is
2060­
0490
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
3
SECTION
S:
SCREENING
INTERVIEW
ABTID
UNIQUE
HOUSEHOLD
IDENTIFICATION
NUMBER
ABTIDHH
UNIQUE
PERSON
IDENTIFICATION
NUMBER
INTRODUCTION:

Hello,
my
name
is
___.
I'm
calling
on
behalf
of
the
U.
S.
Environmental
Protection
Agency.
We're
conducting
a
nationwide
research
study
regarding
indoor
air
quality
and
things
that
may
cause
breathing
problems
such
as
asthma.
This
study
will
help
develop
health
programs
to
improve
indoor
air
quality
for
everyone.
Your
participation
is
voluntary
and
your
answers
will
be
kept
private
in
accordance
with
the
U.
S.
Public
Health
Service
Act.

Am
I
speaking
with
someone
who
lives
in
this
household
who
is
18
years
of
age
or
older?

[
IF
YES,
PROCEED
WITH
INTERVIEW]

S1.
Including
yourself,
has
anyone
living
in
your
household
ever
been
told
by
a
doctor
or
other
health
professional
that
they
have
asthma?

YES
...................................................
1
NO.....................................................
2
REFUSED
.........................................
7
DON'T
KNOW..................................
8
INFORMED
CONSENT
FOR
ASTHMA­
NEGATIVE
HOUSEHOLDS:
Since
no
one
in
your
household
has
asthma,
I
have
just
a
few
more
questions
about
your
household
and
household
members
so
that
we
may
compare
information
about
people
who
do
and
do
not
have
asthma.
Before
we
continue,
I'd
like
you
to
know
that
you
may
choose
not
to
answer
any
question
you
don't
want
to
answer
or
stop
at
any
time
without
penalty
or
loss
of
benefits.
In
order
to
evaluate
my
performance,
my
supervisor
may
record
and
listen
as
I
ask
the
questions.
I'd
like
to
continue
now
with
approximately
5
minutes
of
questions.

INFORMED
CONSENT
FOR
ASTHMA­
POSITIVE
HOUSEHOLDS:
Before
we
continue,
I'd
like
you
to
know
that
you
may
choose
not
to
answer
any
question
you
don't
want
to
answer
or
stop
at
any
time
without
penalty
or
loss
of
benefits.
In
order
to
evaluate
my
performance,
my
supervisor
may
record
and
listen
as
I
ask
the
questions.
I'd
like
to
continue
now
with
approximately
15
minutes
of
questions.
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
4
S2.
So
that
I'll
know
how
to
refer
to
people
in
the
household,
starting
with
yourself,
please
tell
me
the
age
and
sex
of
each
person
living
in
your
household.
After
yourself,
please
list
the
household
members
from
oldest
to
youngest.

INTERVIEWER:
RECORD
AGE
IN
YEARS.
IF
HH
MEMBER
IS
LESS
THAN
1
YEAR
OLD,
ENTER
"
0"

_________
ENTER
AGE
REF  ...­
1
DK   .­
2
S2_
1.
READ
IF
NECESSARY:
And
is
the
[
AGE
YEAR
OLD]
male
or
female?

Male     .
1
Female    .
2
REFUSED  ...
7
DON'T
KNOW...
8
S7_
18.
[
CATI:
IF
S2a
=
­
1
OR
 
2,
ASK
S7,
ELSE
SKIP
TO
S8]
How
many
people
living
in
your
household
are
under
18
years
old?

_________
ENTER
NUMBER
REF  ...­
1
DK   .­
2
S7.
How
many
people
living
in
your
household
are
children
six
years
old
and
younger?

_________
ENTER
NUMBER
REF  ...­
1
DK   .­
2
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
5
HHTOT
DERIVED.
TOTAL
NUMBER
OF
PEOPLE
IN
THE
HOUSEHOLD
TOTADULT
DERIVED.
TOTAL
NUMBER
OF
ADULTS
IN
THE
HOUSEHOLD
TOTKID
DERIVED.
TOTAL
NUMBER
OF
CHILDREN
0­
17
IN
THE
HOUSEHOLD
TOT_
YNGKID
DERIVED.
TOTAL
NUMBER
OF
CHILDREN
0­
6
IN
THE
HOUSEHOLD
S8.
Earlier,
you
told
me
that
you
or
someone
in
your
household
had
been
told
by
a
doctor
or
health
professional
that
they
have
asthma.
Who
would
that
be?

INTERVIEWER:
READ
CHOICES
IF
NECESSARY.
MARK
ALL
THAT
APPLY.

[
CATI:
SHOW
ROSTER
OF
ALL
HOUSEHOLD
MEMBERS
FOR
INTERVIEWER
TO
INDICATE
ASTHMA
STATUS.
FOR
EACH
PERSON
WITH
ASTHMA,
USE
REPONSE
BELOW.]

YES      ..
1
NM_
AA
DERIVED.
NUMBER
OF
ADULTS
WITH
ASTHMA
NM_
CA
DERIVED.
NUMBER
OF
CHILDREN
WITH
ASTHMA
NM_
AWA
DERIVED.
NUMBER
OF
ADULTS
WITHOUT
ASTHMA
NM_
CWA
DERIVED.
NUMBER
OF
CHILDREN
WITHOUT
ASTHMA
S9.
[
CATI:
ADMINISTER
ITEMS
S9­
S12
FOR
EACH
PERSON
WITH
ASTHMA,
THEN
SKIP
TO
S13.]
[
Do
you/
Does
[
the
[
AGE]
year
old]
in
your
home
diagnosed
with
asthma]
still
have
asthma?

YES      ..
1
NO       
2
REFUSED    
7
DON'T
KNOW  
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
6
S10.
How
long
has
it
been
since
[
you/
the
[
AGE]
year
old/
the[
AGE]
year
old
or
the
[
AGE]
year
old's
parent
or
guardian]
last
talked
to
a
doctor
or
other
health
professional
about
[
his
/
her]
asthma?

(
READ
RESPONSES
IF
NECESSARY)

NEVER.............................................................
1
WITHIN
THE
PAST
YEAR
.............................
2
1
YEAR
TO
LESS
THAN
3
YEARS
AGO.......
3
3
YEARS
TO
LESS
THAN
5
YEARS
AGO.....
4
5
OR
MORE
YEARS
AGO...............................
5
REFUSED
........................................................
7
DON'T
KNOW.................................................
8
S11.
How
long
has
it
been
since
[
you/
the
[
AGE]
year
old]
last
took
asthma
medication?

(
READ
RESPONSES
IF
NECESSARY)

NEVER....................................................................
1
LESS
THAN
1
DAY
AGO.......................................
2
1
TO
6
DAYS
AGO,
................................................
3
1
WEEK
TO
LESS
THAN
3
MONTHS
AGO..........
4
3
MONTHS
TO
LESS
THAN
1
YEAR
AGO
..........
5
1
YEAR
TO
LESS
THAN
3
YEARS
AGO..............
6
3
YEARS
TO
LESS
THAN
5
YEARS
AGO
...........
7
MORE
THAN
5
YEARS
AGO
................................
8
REFUSED
.............................................................
97
DON'T
KNOW......................................................
98
S12.
Symptoms
of
asthma
include
coughing,
wheezing,
shortness
of
breath,
chest
tightness
or
phlegm
production
when
[
you
do/
the
[
AGE]
year
old
does
not
have]
a
cold
or
respiratory
infection.
How
long
has
it
been
since
[
you/
the
[
AGE]
year
old]
last
had
any
symptoms
of
asthma?

(
READ
RESPONSES
IF
NECESSARY)

NEVER....................................................................
1
LESS
THAN
1
DAY
AGO.......................................
2
1
TO
6
DAYS
AGO.................................................
3
1
WEEK
TO
LESS
THAN
3
MONTHS
AGO..........
4
3
MONTHS
TO
LESS
THAN
1
YEAR
AGO
..........
5
1
YEAR
TO
LESS
THAN
3
YEARS
AGO..............
6
3
YEARS
TO
LESS
THAN
5
YEARS
AGO
...........
7
MORE
THAN
5
YEARS
AGO
................................
8
REFUSED
.............................................................
97
DON'T
KNOW......................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
7
S13.
[
CATI:
IF
NO
CHILDREN
UNDER
18
LIVE
IN
HOUSEHOLD,
SKIP
TO
S15]

Does
anyone
who
lives
there
smoke
cigarettes,
cigars,
or
pipes
anywhere
inside
your
home?

YES
........................................................
1
NO..........................................................
2
(
SKIP
TO
S14)
REFUSED
..............................................
7
(
SKIP
TO
S14)
DON'T
KNOW.......................................
8
(
SKIP
TO
S14)

S13a.
Who
is
that?
PROBE
IF
NECESSARY:
What
is
their
relationship
to
the
child
(
ren)
in
the
household?
And
he
or
she
lives
there,
correct?
[
MARK
ALL
THAT
APPLY]

MOTHER
(
STEP/
FOSTER/
HALF/
ADOPTIVE)
.................
1
FATHER
(
STEP/
FOSTER/
HALF/
ADOPTIVE)...................
2
SISTER/
BROTHER
(
STEP/
FOSTER/
HALF/
ADOPTIVE)..
3
GRANDPARENT................................................................
4
OTHER
FAMILY
MEMBER
..............................................
5
RESPONDENT'S
PARTNER
OR
BOY/
GIRLFRIEND.......
6
OTHER
NON­
RELATIVE
..................................................
7
REFUSED
.........................................................................
97
DON'T
KNOW..................................................................
98
[
NOTE:
ALL
POSSIBLE
COMBINATIONS
OF
RESPONSES
TO
THIS
QUESTION
HAVE
BEEN
COMBINED
INTO
A
SINGLE
VARIABLE
S13A
IN
THE
ACCOMPANYING
DATA
FILE.]

S13b.
On
the
average,
about
how
many
days
per
week
do
people
who
live
there
smoke
anywhere
inside
your
home?
[
PROBE
FOR
NUMBER
OF
DAYS]

LESS
THAN
ONE
DAY/
RARELY
......................................
1
1
DAY..................................................................................
2
2
DAYS................................................................................
3
3
DAYS................................................................................
4
4­
7
DAYS.............................................................................
5
REFUSED
............................................................................
7
DON'T
KNOW.....................................................................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
8
S14.
Does
anyone
who
visits
there
smoke
cigarettes,
cigars,
or
pipes
anywhere
inside
your
home?

YES
...............................
1
NO.................................
2
(
SKIP
TO
S15)
REFUSED
.....................
7
(
SKIP
TO
S15)
DON'T
KNOW.
.............
8
(
SKIP
TO
S15)

S14a.
On
the
average,
about
how
many
days
per
week
do
people
who
visit
there
smoke
anywhere
inside
your
home?

LESS
THAN
ONE
DAY/
RARELY
......................................
1
1
DAY..................................................................................
2
2
DAYS................................................................................
3
3
DAYS................................................................................
4
4­
7
DAYS.............................................................................
5
REFUSED
............................................................................
7
DON'T
KNOW.....................................................................
8
S15.
What
is
your
zip
code?

SPECIFY:________
(
enter
zip
code)
REFUSED
....................................
­
2
DON'T
KNOW.............................
­
1
S16.
[
Are
you/
Is
[
the
[
AGE]
year
old]
of
Hispanic
or
Latino
origin?

YES      ..
1
NO       
2
REFUSED    
7
DON'T
KNOW  
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
9
S17.
[
NOTE:
A
MAXIMUM
OF
FIVE
RACES
WERE
REPORTED
AND
STORED
IN
VARIABLES
S17_
1
THROUGH
S17_
5.]

Now,
I'm
going
to
read
a
list
of
categories.
Please
choose
one
or
more
of
the
following
categories
to
describe
[
yourself/
the
[
AGE]
year
old].
[
Are
you/
Is
[
the
[
AGE]
year
old]
White,
Black
or
African­
American,
American
Indian,
Alaska
Native,
Asian,
or
Native
Hawaiian
or
other
Pacific
Islander?

WHITE...............................................
1
BLACK/
AFRICAN­
AMERICAN.......
2
AMERICAN
INDIAN
........................
3
ALASKA
NATIVE.............................
4
ASIAN................................................
5
NATIVE
HAWAIIAN
........................
6
PACIFIC
ISLANDER.........................
7
[
NO
OTHER
MENTIONS].................
8
REFUSED
........................................
97
DON'T
KNOW.................................
98
RACE
DERIVED.
RACE
OF
HOUSEHOLD
MEMBER
S18.
What
is
the
highest
level
of
education
completed
by
the
person
in
the
household
who
earns
the
most
money?

NO
FORMAL
SCHOOLING................................................................................
1
LESS
THAN
HIGH
SCHOOL..............................................................................
2
GRADUATED
HIGH
SCHOOL...........................................................................
3
SOME
POST­
HIGH
SCHOOL,
BUT
NOT
A
BACHELOR'S
DEGREE
(
B.
A.)....
4
COLLEGE
GRADUATE
­
BACHELOR'S
DEGREE
OR
B.
A.............................
5
SOME
GRADUATE
OR
PROFESSIONAL
SCHOOL
(
WITH
OR
WITHOUT
DEGREE)                   .
6
REFUSED
............................................................................................................
97
DON'T
KNOW.....................................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
10
RANDOM
SAMPLING
OF
RESPONDENT
FOR
DETAILED
ASTHMA
INTERVIEW
CATI:
IF
(
S1
=
2,
7,
8)
OR
(
S10
=
1,
5,
7,
8
AND
S11=
1,
8,
97,
98
AND
S12=
1,
8,
97,
98
FOR
ALL
ASTHMATICS),
SKIP
TO
OTHER_
T.

ELSE
RANDOMLY
SELECT
ONE
HOUSEHOLD
MEMBER
IDENTIFIED
AS
HAVING
ASTHMA
IN
S8
AND
CONTINUE
TO
A1.

ASTHSTAT
DERIVED.
ASTHMA
STATUS
OF
HOUSEHOLD
MEMBER
DPNUM
FLAG.
ROSTER
NUMBER
OF
PERSON
SELECTED
FOR
DETAILED
INTERVIEW
COMPLETE
DERIVED.
PERSON
COMPLETED
DETAILED
INTERVIEW
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
11
SECTION
A:
DETAILED
INTERVIEW
A_
AGE.
AGE
OF
SAMPLED
RESPONDENT
A1.
First,
I
have
some
questions
about
asthma
medication
and
treatment.
[
Do
you/
Does
the
[
AGE]
year
old]
regularly
take
prescription
medication
on
a
daily
basis
for
[
your/
his/
her]
asthma?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A2.
[
Do
you/
Does
the
[
AGE]
year
old]
take
quick­
acting
prescription
medication
in
response
to
an
asthma
episode
or
attack?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A3.
[
Do
you/
Does
[
the
[
AGE]
year
old]
regularly
monitor
[
your/
his/
her]
lung
function
using
a
peak
flow
meter
or
similar
device?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
HELP
SCREEN:
A
peak
flow
meter
is
a
device
that
measures
how
much
air
you
can
blow
out
of
your
lungs.
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
12
A4.
An
asthma
management
plan
is
a
printed
form
that
tells
when
to
change
the
amount
or
type
of
medicine,
when
to
call
a
doctor
for
advice,
and
when
to
go
to
the
emergency
room.
Has
a
doctor
or
other
health
professional
EVER
given
[
you/
the
[
AGE]
year
old
or
the
[
AGE]
year
old's
parent
or
guardian]
an
asthma
management
plan?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
INTRODUCTION
TO
A5
SERIES:

I
am
going
to
read
a
list
of
things
that
may
affect
asthma
symptoms.
For
each
item,
please
tell
me
whether
or
not
you
think
any
of
these
things
commonly
affect
asthma
symptoms
in
asthmatics
generally,

not
just
in
[
you/
the
[
AGE]
year
old].

A5a.
What
about
pollen?
[
PROBE,
IF
NEEDED:
Do
you
think
pollen
commonly
affects
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old]?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A5b.
Molds?
[
PROBE,
IF
NEEDED:
Do
you
think
molds
commonly
affect
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
13
A5c.
Dust
mites?
[
PROBE,
IF
NEEDED:
Do
you
think
dust
mites
commonly
affect
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A5d.
Cats?
[
PROBE,
IF
NEEDED:
Do
you
think
cats
commonly
affect
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A5e.
<
A5E>
Dogs?
[
PROBE,
IF
NEEDED:
Do
you
think
dogs
commonly
affect
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A5f.
<
A5F>
Cockroaches?
[
PROBE,
IF
NEEDED:
Do
you
think
cockroaches
commonly
affect
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
14
A5g.
High
ozone
outside?
[
PROBE,
IF
NEEDED:
Do
you
think
high
ozone
outside
commonly
affects
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A5h.
Secondhand
tobacco
smoke?
[
PROBE,
IF
NEEDED:
Do
you
think
secondhand
tobacco
smoke
commonly
affects
asthma
symptoms
in
asthmatics
generally,
not
just
in
[
you/
the
[
AGE]
year
old?]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
INTRODUCTION
TO
A6
SERIES:

Next,
I
have
some
questions
about
things
that
may
trigger
[
your/
the
[
AGE]
year
old's]
asthma.

A6a.
Do
molds
trigger
[
your/
the
[
AGE]
year
old's]
asthma?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A6b.
Do
cockroaches
trigger
[
your/
the
[
AGE]
year
old's]
asthma?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
15
A6c.
Do
dust
mites?
[
PROBE
IF
NEEDED:
Do
dust
mites
trigger
[
your/
the
[
AGE]
year
old's]

asthma?]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A6d.
Do
cats?
[
PROBE
IF
NEEDED:
Do
cats
trigger
[
your/
the
[
AGE]
year
old's]
asthma?]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A6e.
Do
dogs?
[
PROBE
IF
NEEDED:
Do
dogs
trigger
[
your/
the
[
AGE]
year
old's]
asthma?]

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
16
A6f.
[
NOTE:
A
MAXIMUM
OF
FIVE
RESPONSES
WERE
REPORTED
AND
STORED
IN
A6FS1
THROUGH
A6FS5.]

Does
anything
else
trigger
[
your/
the
[
AGE]
year
old's]
asthma?

(
CHECK
ALL
THAT
APPLY)

WEATHER....................................................................
1
EXERCISE....................................................................
2
EMOTIONAL
UPSET...................................................
3
NOTHING
ELSE...........................................................
4
AIR
CONDITIONING....................................................
5
ALLERGIES...................................................................
6
ANIMALS
(
OTHER
THAN
CATS
&
DOGS)
...................
7
CHEMICAL
FUMES/
CLEANING
AGENTS
...................
8
DUST.............................................................................
9
FLOWERS/
PLANTS.....................................................
10
FOODS........................................................................
11
PERFUMES/
BODY
SPRAYS
........................................
12
POLLEN......................................................................
13
POLLUTION................................................................
14
SECONDHAND
SMOKE
.............................................
15
SICKNESS
OR
ILLNESS
..............................................
16
SMOKE
(
IN
GENERAL
NOT
SPECIFIED)
..................
17
OTHER
 
Specify:
_____
..........................................
95
REFUSED
...................................................................
97
DON'T
KNOW............................................................
98
A6FALL
DERIVED.
ANYTHING
ELSE
TRIGGERS
ASTHMA
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
17
A7.
[
Have
you/
has
[
the
[
AGE]
year
old]
seen
a
doctor
to
diagnose
what
things
may
trigger
[
your/
the
[
AGE]
year
old's]
asthma?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A8.
[
CATI:
IF
NO
CHILDREN
UNDER
18
IN
HH,
SKIP
TO
A9]

Is
smoking
allowed
in
your
home?

SMOKING
IS
PERMITTED
ANYWHERE
AT
ANY
TIME         ...
1
SMOKING
IS
PERMITTED
ONLY
IN
SOME
PLACES
OR
AT
SOME
TIMES ..
2
SMOKING
IS
NOT
PERMITTED
ANYWHERE
AT
ANY
TIME       ..
3
REFUSED
                             .
7
DON'T
KNOW                  .
         .
8
INTRODUCTION
TO
A9
SERIES:

Now
I
have
some
questions
about
your
living
environment.

A9a.
[
CATI:
ASK
IF
(
A6a
=
1,7,
OR
8).
ELSE
SKIP
TO
A9c].

Do
you
ever
notice
mold
in
your
home?
Do
not
include
mold
on
food.

YES
......................................
1
NO........................................
2
[
SKIP
TO
A9c]
REFUSED
............................
7
[
SKIP
TO
A9c]
DON'T
KNOW.....................
8
[
SKIP
TO
A9c]

A9b.
Is
the
mold
cleaned
as
soon
as
it
is
noticed?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
18
A9c.
[
CATI:
ASK
IF
(
either
A6a
or
A6c=
1,7,
OR
8).
ELSE
SKIP
TO
A9e].

Is
a
dehumidifier
used
to
reduce
excess
humidity
in
your
home?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9c1.
Is
an
air
conditioner
used
in
your
home?

NOTE:
INCLUDE
AIR
CONDITIONER
USE
FOR
COOLING
THE
HOME.

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9d.
Is
an
exhaust
fan
or
open
window
regularly
used
in
your
kitchen
to
reduce
humidity?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
HELP
SCREEN:
THIS
INCLUDES
HUMIDITY
FROM
COOKING,

DISHWASHING,
ETC.

THE
TERM
"
REGULARLY"
SHOULD
BE
DEFINED
BY
RESPONDENT.
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
19
A9d1.
Is
an
exhaust
fan
or
open
window
regularly
used
in
your
bathroom
to
reduce
humidity?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
HELP
SCREEN:
THIS
INCLUDES
HUMIDITY
FROM
BATHING,
SHOWERING,

ETC.

IF
RESPONDENT
INDICATES
THEY
HAVE
MORE
THAN
ONE
BATHROOM,
THIS
QUESTION
REFERS
TO
THE
BATHROOM
THEY
USE
MOST
FREQUENTLY
FOR
SHOWERING
AND
BATHING.
THE
TERM
"
REGULARLY"
SHOULD
BE
DEFINED
BY
RESPONDENT.

A9e.
[
CATI:
ASK
IF
(
A6b=
1,
7,
OR
8).
ELSE
SKIP
TO
A9h.]

Have
you
ever
noticed
cockroaches
in
your
home?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9e1.
Are
indoor
areas
in
your
home
kept
clean
to
discourage
cockroaches?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9f.
Is
food
stored
in
tight
containers
in
your
home
to
discourage
cockroaches?

YES
..........................................................................
1
NO............................................................................
2
NOT
NEEDED.........................................................
3
REFUSED
................................................................
7
DON'T
KNOW.........................................................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
20
A9g.
[
CATI:
IF
A9e=
2,
SKIP
TO
A9h]

If
you
ever
discover
cockroaches,
what
is
the
main
method
you
use
to
control
them?

USE
BORIC
ACID
..........................................................................
1
USE
ROACH
PESTICIDAL
SPRAY
(
LIKE
RAID).........................
2
USE
ROACH
TRAPS
.....................................................................
3
DO
NOTHING
TO
CONTROL
ROACHES.....................................
4
EXTERMINATOR.............................................................................
5
LANDLORD
TAKES
CARE
OF
IT....................................................
6
OTHER
(
SPECIFY:____________).
..............................................
95
REFUSED......................................................................................
97
DON'T
KNOW..............................................................................
98
A9h.
[
CATI:
ASK
IF
(
A6c=
1,
7,
OR
8).
ELSE
SKIP
TO
A9k]
[
Do
you/
Does
[
the
[
AGE]
year
old]
use
either
a
mattress
cover
or
pillow
covers
that
are
made
especially
for
controlling
dust
mites?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9i.
Are
the
sheets
and
pillow
cases
of
the
person
with
asthma
washed
in
hot
water
on
a
weekly
basis?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9j.
Have
actions
been
taken
to
reduce
the
use
of
fabric
covered
cushioned
furniture
in
your
home?

YES
....................................
1
NO......................................
2
NO
CUSHIONED
FURNITURE......................
3
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
21
A9k.
[
CATI:
ASK
IF
(
A6d=
1,7,
OR
8).
ELSE
SKIP
TO
A9n]
Does
anyone
in
your
household
have
a
cat?

YES
........................................................
1
NO..........................................................
2
[
SKIP
TO
A9n]
REFUSED
..............................................
7
[
SKIP
TO
A9n]
DON'T
KNOW.......................................
8
[
SKIP
TO
A9n]

A9l.
Is
the
cat
ever
allowed
inside
the
house?

YES
........................................................
1
NO..........................................................
2
[
SKIP
TO
A9n]
REFUSED
..............................................
7
[
SKIP
TO
A9n]
DON'T
KNOW.......................................
8
[
SKIP
TO
A9n]

A9m.
Is
the
cat
ever
allowed
in
[
your/
the
[
AGE]
year
old's]
bedroom?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
A9n.
[
CATI:
ASK
IF
(
A6e=
1,
7,
or
8).
ELSE
SKIP
TO
A10]

Does
anyone
in
your
household
have
a
dog?

YES
...........................................
1
NO.............................................
2
[
SKIP
TO
A10]
REFUSED
.................................
7
[
SKIP
TO
A10]
DON'T
KNOW..........................
8
[
SKIP
TO
A10]

A9o.
Is
the
dog
ever
allowed
inside
the
house?

YES
...........................................
1
NO.............................................
2
[
SKIP
TO
A10]
REFUSED
.................................
7
[
SKIP
TO
A10]
DON'T
KNOW..........................
8
[
SKIP
TO
A10]
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
22
A9p.
Is
the
dog
ever
allowed
in
[
your/
the
[
AGE]
year
old's]
bedroom?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
INTRODUCTION
TO
A10
SERIES:
The
next
[
question
is/
questions
are]
about
things
that
might
keep
you
from
reducing
asthma
triggers
in
your
home.

A10a.
[
CATI:
ASK
IF
(
A6a=
1
AND
A9b=
2)
ELSE,
SKIP
TO
A10b.]
Earlier,
you
mentioned
that
mold
triggers
[
your
/
the
[
AGE]
year
old's]
asthma,
but
mold
is
not
cleaned
as
soon
as
it's
noticed
in
your
home.
What
is
the
main
reason
mold
is
not
cleaned
as
soon
as
it
is
noticed?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
23
A10b.
[
CATI:
ASK
IF
(
A6a=
1
or
A6c=
1)
AND
(
A9c=
2
or
A9c1=
2),
ELSE,
SKIP
TO
A10c.]
Earlier,
you
mentioned
that
[
mold
/
dust
mites
/
mold
and
dust
mites]
[
triggers/
trigger]
[
your
/
the
[
AGE]
year
old's]
asthma,
but
[
an
air
conditioner/
a
dehumidifier/
an
air
conditioner
or
dehumidifier]
is
not
used
to
reduce
extra
humidity
in
your
home.
What
is
the
main
reason
that
[
an
air
conditioner/
dehumidifier/
air
conditioner
or
dehumidifier]
is
not
used
in
your
home?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
HAVE
HUMIDITY
IN
OUR
HOUSE/
WHERE
WE
LIVE
..................
7
DON'T
OWN
ONE.......................................................................................
8
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
NO
REASON..............................................................................................
10
WOOD
HEAT
IS
USED
IN
HOME.............................................................
13
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
A10c.
[
CATI:
ASK
IF
(
A6a=
1
OR
A6c=
1)
AND
(
A9d=
2
or
A9d1=
2).
ELSE,
SKIP
TO
A10d.]
Earlier,
you
mentioned
that
[
molds/
molds/
molds
and
dust
mites]
[
trigger/
triggers]
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
exhaust
fans
or
open
windows
are
not
used
in
the
[
kitchen/
bathroom/
kitchen
or
bathroom]
to
reduce
humidity.
What
is
the
main
reason
that
exhaust
fans
or
open
windows
are
not
used?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
HAVE
HUMIDITY
IN
OUR
HOUSE/
WHERE
WE
LIVE
..................
7
DON'T
OWN
ONE.......................................................................................
8
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
NO
REASON..............................................................................................
10
NO
WINDOWS/
EXHAUST
FAN
IN
ROOM
OR
HOUSE
............................
11
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
24
A10d.
[
CATI:
ASK
IF
(
A6b=
1
AND
A9e1=
2),
ELSE,
SKIP
TO
A10d1.]
Earlier,
you
mentioned
that
cockroaches
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
indoor
areas
in
your
home
are
not
kept
clean
to
discourage
cockroaches.
What
is
the
main
reason
that
indoor
areas
in
your
home
are
not
kept
clean?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
A10d1.
[
CATI:
ASK
IF
(
A6b=
1
AND
A9f=
2),
ELSE,
SKIP
TO
A10e.]
Earlier,
you
mentioned
that
cockroaches
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
food
is
not
stored
in
tight
containers
to
discourage
cockroaches.
What
is
the
main
reason
that
food
is
not
stored
in
tight
containers?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
A10e.
[
CATI:
ASK
IF
(
A6b=
1
AND
A9g=
4)
ELSE,
SKIP
TO
A10f.]
Earlier,
you
mentioned
that
cockroaches
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
nothing
is
done
to
control
roaches
when
they
are
discovered
in
your
home.
What
is
the
main
reason
that
nothing
is
done
to
control
roaches
when
they
are
discovered?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
25
A10f.
[
CATI:
ASK
IF
(
A6c=
1
AND
A9h=
2)
ELSE,
SKIP
TO
A10g.]
Earlier,
you
mentioned
that
dust
mites
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
a
mattress
cover
or
pillow
covers
made
especially
for
controlling
dust
mites
are
not
used
in
your
home.
What
is
the
main
reason
that
these
mattress
cover
or
pillow
covers
are
not
used?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
OWN
ONE.......................................................................................
8
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
NO
REASON..............................................................................................
10
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
A10g.
[
CATI:
ASK
IF
(
A6c=
1
AND
A9i=
2)
ELSE,
SKIP
TO
A10h.]
Earlier,
you
mentioned
that
dust
mites
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
[
your/[
the
[
AGE]
year
old]'
s]
sheets
and
pillow
cases
are
not
washed
in
hot
water
on
a
weekly
basis.
What
is
the
main
reason
that
sheets
and
pillow
cases
are
not
washed
in
hot
water
weekly?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
OWN
ONE.......................................................................................
8
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
NO
REASON..............................................................................................
10
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
26
A10h.
[
CATI:
ASK
IF
(
A6c=
1
AND
A9j=
2)
ELSE,
SKIP
TO
A10i.]
Earlier,
you
mentioned
that
dust
mites
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
actions
have
not
been
taken
to
reduce
the
use
of
cushioned
furniture
in
your
home.
What
is
the
main
reason
that
use
of
fabric
covered
cushioned
furniture
has
not
been
reduced?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
HAVE
HUMIDITY
IN
OUR
HOUSE/
WHERE
WE
LIVE
..................
7
DON'T
OWN
ONE.......................................................................................
8
NEVER
THOUGHT
ABOUT
IT/
DIDN'T
KNOW..........................................
9
NO
REASON..............................................................................................
10
NOT
A
LOT
OF
FABRIC
COVERED
FURNITURE
IN
OUR
HOME..........
12
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
A10i.
[
CATI:
ASK
IF
(
A6d=
1)
AND
(
A9l=
1
OR
IF
A9m=
1).
ELSE,
SKIP
TO
A10l.]
Earlier,
you
mentioned
that
cats
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
[
your
cat
is
not
kept
outside
of
the
house/
your
cat
is
not
kept
out
of
[
your/[
the
[
AGE]
year
old]'
s]
bedroom].
What
is
the
main
reason
that
the
cat
is
not
kept
out?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
DON'T
OWN
ONE.......................................................................................
8
NO
REASON..............................................................................................
10
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
27
A10j.
[
CATI:
ASK
IF
(
A6e=
1)
AND
(
A9o=
1
OR
IF
A9p=
1.
ELSE,
SKIP
TO
D1.]
Earlier,
you
mentioned
that
dogs
trigger
[
your
/
[
the
[
AGE]
year
old's]
asthma,
but
[
your
dog
is
not
kept
outside
of
the
house/
your
dog
is
not
kept
out
of
[
your/[
the
[
AGE]
year
old]'
s]
bedroom].
What
is
the
main
reason
that
the
dog
is
not
kept
out?
[
SELECT
ONLY
ONE].

I
DON'T
HAVE
TIME
................................................................................
1
IT
COSTS
TOO
MUCH..............................................................................
2
IT
DOESN'T
WORK...................................................................................
3
I
DO
SOMETHING
ELSE
TO
ADDRESS
THE
PROBLEM.......................
4
I
DON'T
WANT
TO
DO
IT.........................................................................
5
MEDICATIONS
ARE
ALL
THAT
IS
NEEDED.........................................
6
NO
REASON..............................................................................................
10
OTHER
(
SPECIFY:
_________________)
...............................................
95
REFUSED
...
............................................................................................
97
DON'T
KNOW.........................................................................................
98
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
28
D.
DEMOGRAPHIC
INFORMATION
OTHER_
T.
Now,
I
just
have
a
few
more
general
questions
about
you
and
your
household.
Do
you
have
any
other
home
phone
numbers
in
addition
to
[
IAREA
CODE
AND
TELEPHONE
NUMBER
CALLED]?
Please
do
not
include
cellular
phones
in
your
answer.

YES
......................................
1
NO........................................
2
[
SKIP
TO
D3]
REFUSED
............................
7
[
SKIP
TO
D3]
DON'T
KNOW.....................
8
[
SKIP
TO
D3]

SEC_
USE.
Is
this
second
number
for
home
use
only,
for
business
use
only,
or
for
both
home
and
business
use?

HOME
ONLY.......................................
1
BUSINESS
ONLY................................
2
[
SKIP
TO
THIRD_
TN]
BOTH
HOME
AND
BUSINESS...........
3
REFUSED.............................................
7
[
SKIP
TO
THIRD_
TN]
DON'T
KNOW.....................................
8
[
SKIP
TO
THIRD_
TN]

SEC_
FAX.
Is
this
second
number
used
only
for
computer
or
fax
communications?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
THIRD_
TN.
Do
you
have
a
third
home
phone
number
in
addition
to
the
two
you
have
already
told
me
about?
Please
do
not
include
cellular
phones
in
your
answer.

YES.................................
1
NO
..................................
2
[
SKIP
TO
WO_
SERVICE]
REFUSED.......................
7
[
SKIP
TO
WO_
SERVICE]
DON'T
KNOW...............
8
[
SKIP
TO
WO_
SERVICE]
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
29
THIRD_
USE.
Is
this
third
number
for
home
use
only,
for
business
use
only,
or
for
both
home
and
business
use?

HOME
ONLY.......................................
1
BUSINESS
ONLY................................
2
[
SKIP
TO
WO_
SERVICE]
BOTH
HOME
AND
BUSINESS...........
3
REFUSED.............................................
7
[
SKIP
TO
WO_
SERVICE]
DON'T
KNOW.....................................
8
[
SKIP
TO
WO_
SERVICE]

THIRD_
FAX.
Is
this
third
number
used
only
for
computer
or
fax
communications?

YES
....................................
1
NO......................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
NUM_
PHON
DERIVED.
NUMBER
OF
PHONE
LINES
IN
HOUSEHOLD
WO_
SERVICE.
During
the
past
12
months,
has
your
household
been
without
telephone
service
for
1
week
or
more?
Please
do
not
include
cellular
phones
in
your
answer.

YES.................................
1
NO
..................................
2
[
SKIP
TO
D4]
REFUSED.......................
7
[
SKIP
TO
D4]
DON'T
KNOW...............
8
[
SKIP
TO
D4]

D3a.
For
how
long
was
your
household
without
telephone
service
in
the
past
12
months?

ENTER
NUMBER
___
___
___
(­
1)
REFUSED
(­
2)
DON'T
KNOW
D3b.
ENTER
PERIOD
DAYS           ....
1
WEEK(
S)         .. .
2
MONTH(
S)
        . .
3
REFUSED          ..
7
DON'T
KNOW        .
8
NOPHONE
DERIVED.
NUMBER
OF
DAYS
WITHOUT
TELEPHONE
SERVICE
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
30
D4.
What
was
the
total
combined
income
of
your
household
in
2002?
Can
you
tell
me
that
amount
before
taxes?

PROBE
IF
NEEDED:
Include
income
from
all
sources
including
wages,
salaries,
unemployment
payments,
public
assistance,
Social
Security
or
retirement
benefits,
help
from
relatives
and
so
forth.

RECORD
INCOME
(
SPECIFY:
____________)
[
SKIP
TO
CLOSING
SCRIPT]
(­
1)
REFUSED
(­
2)
DON'T
KNOW
D5.
For
the
purposes
of
this
survey,
it
is
important
to
get
at
least
a
range
for
the
total
income
received
by
all
members
of
your
household
in
2002.
Would
you
say
that
the
total
combined
income,
before
taxes
was
[
INSERT
APPLICABLE
FILL
FROM
TABLE
BELOW]?

[
CATI:
For
1
person
household]
More
or
less
than
$
9,000
[
CATI:
For
2
person
household]
More
or
less
than
$
12,000
[
CATI:
For
3
person
household]
More
or
less
than
$
15,000
[
CATI:
For
4
person
household]
More
or
less
than
$
18,000
[
CATI:
For
5
person
household]
More
or
less
than
$
22,000
[
CATI:
For
6
person
household]
More
or
less
than
$
25,000
[
CATI:
For
7
person
household]
More
or
less
than
$
28,000
[
CATI:
For
8
person
household]
More
or
less
than
$
31,000
[
CATI:
For
9
person
household]
More
or
less
than
$
34,000
[
CATI:
For
10
person
household]
More
or
less
than
$
37,000
[
CATI:
For
11
person
household]
More
or
less
than
$
40,000
[
CATI:
For
12
person
household]
More
or
less
than
$
44,000
[
CATI:
For
13
person
household]
More
or
less
than
$
47,000
[
CATI:
For
14
person
household]
More
or
less
than
$
50,000
[
CATI:
For
15
person
household]
More
or
less
than
$
53,000
MORE
................................
1
LESS
..................................
2
REFUSED
..........................
7
DON'T
KNOW...................
8
National
Survey
on
Environmental
Management
of
Asthma
and
Children's
Exposure
to
Environmental
Tobacco
Smoke:
Questionnaire
31
BELOWPOV
DERIVED.
HOUSEHOLD
INCOME
BELOW
POVERTY
OVERSAMPLE
FLAG.
CASE
IS
PART
OF
LOW­
INCOME
ADULT
OVERSAMPLE
CLOSING
SCRIPT
FOR
ASTHMA­
NEGATIVE
HOUSEHOLDS:
This
concludes
the
interview.
Thank
you
very
much
for
your
time.
If
you
have
any
questions
about
this
survey,
you
may
call
my
supervisor
toll­
free
at
1­
888­
XXX­
XXXX.
Thanks
again.

CLOSING
SCRIPT
FOR
ASTHMA­
POSITIVE
HOUSEHOLDS:
This
concludes
the
interview.
Thank
you
very
much
for
your
time.
If
you
have
any
questions
about
this
survey,
you
may
call
my
supervisor
toll­
free
at
1­
888­
XXX­
XXXX.
If
you
would
like
to
receive
free
information
from
the
EPA
about
managing
asthma
in
the
home,
I
can
give
you
a
telephone
number
to
call
or
website
to
visit.

TERM_
4.
Would
you
like
the
number
or
website?

YES
......................................
1
NO........................................
2
REFUSED
............................
7
DON'T
KNOW.....................
8
IF
YES:
Please
call
EPA's
Indoor
Air
Quality
hotline
at
1­
800­
438­
4318
and
request
the
brochure
called
"
Clear
Your
Home
of
Asthma
Triggers."
Their
website
address
is:
www.
epa.
gov/
iaq.
Thank
you
again
for
your
participation.
Goodbye.

IF
NO,
DON'T
KNOW,
REFUSED:
Thank
you
again
for
your
participation.
Goodbye.
