Agency for Toxic Substances and Disease Registry
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Name: _____________________________ | Date Completed:_______________ | |||||
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Date moved in: ___________________________ |
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Parents and other adults in the home: _____________________________________ __________________________________________________________________ |
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1. Do you think you or a family member have a health problem caused by your home environment? | ||||||
_____ Yes | _____ No | |||||
2. Building type: | ||||||
_____ Single-family, detached | _____ Single-family, condo | |||||
_____ Mobile home | _____ Multifamily | |||||
3. Features: |
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_____Single story | _____ Multistory | _____ Attached garage | ||||
4. Lowest level of home: | ||||||
_____ On-grade level |
_____ Crawl space |
_____ Below-grade basement | ||||
_____ Dirt floor | _____ Finished floor (material: ) | |||||
5. Ownership: | ||||||
_____ Self | _____ Other family member | |||||
_____ Tenant | ||||||
6. Year built:________ | ||||||
Location: | ||||||
_____ Industrial or agricultural pollution sources nearby (<1 mile) | ||||||
_____ Livestock | _____ Commercial orchards, fields | |||||
_____ Hazardous waste site | _____ Industry or business | |||||
_____ Municipal landfills | _____ Underground tanks | |||||
7. Does anyone living in the household smoke tobacco products? | ||||||
_____ Yes | _____ No | |||||
If yes, how many smokers at home? | ||||||
Is there a child in your family exposed to smoke at day care or in cars? | ||||||
_____ Yes | _____ No | |||||
8. Have there been renovations, interior decorating, or new furniture in the home in the last 3 years? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe: ________________________________________ | ||||||
9. How do you heat your home? | ||||||
a. Primary energy source: | ||||||
_____ Oil | _____ Natural gas | _____ Propane | ||||
_____ Wood | _____ Solar | _____ Coal | ||||
_____ Electric heat pump | ||||||
b. Distribution of heat: | ||||||
_____ Forced air | _____ Steam | |||||
_____ Radiant | _____ Hot water | |||||
c. Do you use another heat source? | ||||||
_____ Yes | _____ No | |||||
d. Secondary energy source(s): | ||||||
_____ Oil | _____ Propane | _____ Natural gas | ||||
_____ Wood | _____ Electric | _____ Heat pump | ||||
_____ Coal | _____ Solar | _____ Kerosene | ||||
e. Location of secondary heat source: ______________ | ||||||
f. If this heat source burns fuel, is it vented outdoors? | ||||||
_____ Yes | _____ No | |||||
g. If you use a wood stove or fireplace, how often do you use it? | ||||||
_____ Rarely | _____ Every week of winter | |||||
_____ Every day of winter | ||||||
10. Do you have any of the following equipment or appliances? | ||||||
Air filter (Describe __________________________________________________) | ||||||
Humidifier (Describe _________________________________________________) | ||||||
Air conditioner (Describe _____________________________________________) | ||||||
Gas appliances: | ||||||
_____ Kitchen stove | _____ Hot water heater | _____ Dryer | ||||
11. Do you or a family member have a hobby or home business that might involve | ||||||
_____ biologic agents | _____ chemicals | _____ dusts | ||||
_____ fibers | _____ fumes | _____ radiation | ||||
_____ loud noise | _____ vibration | _____ metals | ||||
_____ paints | ||||||
_____ extreme heat or cold | ||||||
For those that apply, please list and/or describe the hobby: ______________________ |
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12. Is any part of your home damp or have you had a major leak or flood in your house? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe | ||||||
13. Have any pesticides or herbicides been used in or around your home within the last year (including on pets)? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe | ||||||
14. Have you ever tested your home for radon? | ||||||
_____ Yes | _____ No | |||||
If yes, in which season of the year did you test your home? | ||||||
_____ Spring | _____ Summer | |||||
_____ Fall | _____ Winter | |||||
In which part of your home did you conduct the test? ________________________ | ||||||
What was the length of test? ____________________________________ | ||||||
What levels of radon, if any, were found? ___________________________ | ||||||
Have any radon reduction measures been taken? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe ________________________________________________ | ||||||
____________________________________________________ | ||||||
If radon reduction measures have been taken, have the levels been rechecked? | ||||||
_____ Yes | _____ No | |||||
If yes, were the radon levels reduced? | ||||||
_____ Yes | _____ No | |||||
15. Where do you get your water supply? | ||||||
_____ Bottled | _____ Municipal | _____ Private well or spring | ||||
If you get your water from a well, was the well _____dug or _____drilled? | ||||||
When was the well last tested for contaminants? ____________________________ | ||||||
What were the results? _______________________________________________ | ||||||
___________________________________________________ | ||||||
___________________________________________________ | ||||||
16. Do you use a water treatment device in your well (e.g., filter or softener)? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe ________________________________________________ | ||||||
___________________________________________________ | ||||||
17. Do you have a _____septic system or do you use _____municipal sewers? | ||||||
If you use a septic system, when was the tank last pumped? ____________________ | ||||||
18. Does any member of the household work at a job that might result in bringing chemicals home on his or her clothes or shoes? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe ________________________________________________ | ||||||
___________________________________________________ | ||||||
19. Have industrial chemicals been brought home from the workplace for domestic use? | ||||||
_____ Yes | _____ No | |||||
If yes, please describe ________________________________________________ | ||||||
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