ࡱ> q ܱbjbjt+t+ DAAm]ffffH(Dllll<(Tl{RR 6&d&&&2Zy57@BBBBBB$f:7/\277fHff&& 0"HHH7f&&@llffff7@HH9P'NH@&| Ki'll< ALLIES AGAINST ASTHMA EXIT INTERVIEW STUDY ID # ______________________ INTERVIEW DATE _____/_____/_____ MM/DD/YYYY Return Visit Date _____/_____/_____ (if needed) MM/DD/YYYY INTERVIEWERS INITIALS ________________ LANGUAGE OF INTERVIEW English .1 Spanish 2 Vietnamese .3 (During the course of the assessment, record temperature below) Living room or common family spaceChild's bedroomHot water from kitchen sinkA8. Temperature a. _________ b. _________ c. ________ Introduction (For interviewer to read(: The purpose of this interview is to collect some information about your childs asthma one year after you enrolled in our program. I will be asking you questions about your childs asthma and about the environment in your home as it relates to your childs asthma and safety. Toward the end of the interview, I will take a look at a key few rooms in the house, and ask some questions specifically about the rooms. The information you provide will help us understand if and how our program makes a difference. The information will also be used in our research to figure out what kind of assistance to give families that we work with in the future. If there is a question you do not want to answer, please let me know and we can skip it. All of your responses are confidential and will not affect any of the services you receive from your clinic or anywhere else. SECTION 1 - ASTHMA SEVERITY (For interviewer to read(: These questions ask about how often asthma affected you and (CHILD) each day. The questions ask about asthma symptoms during two different time periods: in the last 14 days, and over the last 12 months. It is important to be as accurate as possible. [Show calendar to CARETAKER and identify specific dates being referred to] (For interviewer to read(: Asthma symptoms include wheezing, coughing, tightness in the chest, shortness of breath, waking up at night because of asthma symptoms, and slowing down of usual activities. Now I am going to ask you about each of the specific types of asthma symptoms: AS1. During the daytime in the last 14 days, how many days did (CHILD) have asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ________ days [Enter 0 for None, 99 for Don't Know] AS1_1. How about in the last 12 months? __________ days Begin with a PAUSE, if no answer restate the question. Avoid ranges: if given a range, i.e. 2 to 5 days a month, ask, would that be closer to 2 or closer to 5? Is that every month? If respondent says it varies during the year ask at the worst time how many days a month? For how many months? And the rest of the year, how many days a month? If respondent says most of the time, or all of the time etc. restate the response do you mean a few days a week? How many? Do you mean every day of the year? [INTERVIEWER: Calculate and enter responses adjusted for 12 months.] AS2. During the nighttime in the last 14 nights, how many nights did (CHILD) wake up because of asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough?________ nights AS2_1. How about in the last 12 months? __________ nights [Use same probes as above replacing term days with nights.] AS3. During the past 14 days, that is during the past fourteen 24 hour periods that include daytime and nighttime, did [CHILD] have any asthma symptoms, such as wheezing, coughing, tightness in the chest, shortness of breath, waking up at night because of asthma symptoms, or slowing down of usual activities because of asthma? ______days SECTION 2 EXPOSURE TO COMMUNITY EVENTS & PROGRAMS RELATED TO ASTHMA (For interviewer to read(: Now I'm going to ask you some questions about your community: E1) Have you heard of the King County Asthma Forum? yeS 1 no 2 dont know 9 [If NO or DONT KNOW, go to #3. If YES, go to #2 and ask]: E2) How many times have you participated in activities or received help from the King County Asthma Forum? {Probe if per week, month, year} /week /month /year NEVER 98 DONT KNOW 99 E3) How often do you hear someone in your neighborhood talking about asthma? very often 1 sometimes 2 Seldom 3 never 4 don't know 9 E4) Have you or your child talked with a doctor or nurse about your childs asthma in the last 6 months? yeS 1 no 2 dont know 9 E5) Has anyone visited your home to talk with you about your childs asthma in the last 6 months? yeS 1 no 2 dont know 9 E6) Has anyone called you on the phone to talk with you about your childs asthma in the last 6 months? yeS 1 no 2 dont know 9 E7) Have you or your child attended a class on asthma in your child's school in the last 6 months? yeS 1 no 2 dont know 9 E8) Have you or your child attended a class on asthma at any other place, like a health clinic, neighborhood center, or church in the last 6 months? yeS 1 no 2 dont know 9 E9) Have you or your child participated in some other activity for people with asthma such as a health fair, asthma camp, or neighborhood event in the last 6 months? yeS 1 no 2 dont know 9 E10) Have you heard a presentation on asthma in a church or some other community organization in the last 6 months? yeS 1 no 2 dont know 9 E11) Have you received hand-outs or fliers or manuals on asthma in the last 6 months? yeS 1 no 2 dont know 9 E12) Have you noticed posters or billboards or other announcements in your neighborhood about asthma in the last 6 months? yeS 1 no 2 dont know 9 E13) Have you been to an asthma support group in the last 6 months? yeS 1 no 2 dont know 9 SECTION3 PARENT ASTHMA MANAGEMENT STRATEGIES (For interviewer to read(: Id like to ask you about things you may have done to manage [CHILDS] asthma at home during the past 12 months. For each item, please tell me how often you did these things: all the time, fairly often, not too often, never: How often did you:  All the time  Fairly often Not too often Never Give (CHILD) asthma prescription medicine when he/she was having symptoms.  4 3 2 1 Find ways to keep yourself and (CHILD) calm when he/she was having symptoms.  4 3 2 1 Have (CHILD) rest or play quietly when he/she was having symptoms.  4 3 2 1 Take (CHILD) away from what caused the symptoms.  4 3 2 1 Ask someone for help or advice about managing (CHILD)s asthma.  4 3 2 1 Give (CHILD) asthma medicines before he/she had contact with something that might cause wheezing or coughing, for example, before entering a smoky restaurant or before he/she played sports.  4 3 2 1Clark, N.M., Gong, M, Kaciroti, N. A model of self-regulation for control of chronic disease. Health Education & Behavior 28(6):769-782, 2000. SECTION 4 SOCIAL SUPPORT (For interviewer to read(: This question asks about how much help you get in dealing with your childs asthma. There is no right or wrong answer. Different people want and get different types help. SS1. Do you have at least one person who is not a medical provider that you can count on to help you take care of your child's asthma? yeS (1 no (2 dont know (9 SECTION 5 PEDIATRIC ASTHMA CAREGIVER ASTHMA QUALITY OF LIFE QUESTIONNAIRE (For interviewer to read(: When a child has asthma, the parents or caregivers life is also affected. This section is designed to find out how you have been during the last week. We want to know about the ways in which your childs asthma has affected your normal daily activities and how this has made you feel. It is important that you understand we are not judging you by your responses; we understand that asthma can be challenging and frustrating. We hope you will be open with us in answering these questions, since the information will help us understand the type of support needed by caregivers of children with asthma. [Show response card] During the past week, how often: All of the timeMost of the timeQuite oftenSome of the timeOnce in a whileHardly any of the timeNone of the time QL1. Did you feel helpless or frightened when your child experienced cough, wheeze, or breathlessness?1234567 QL2. Did your family need to change plans because of your childs asthma?1234567 QL3. Did you feel frustrated or impatient because your child was irritable due to asthma?1234567 QL4. Did your childs asthma interfere with your job or work around the house?1234567 QL5. Did you feel upset because of your childs cough, wheeze, or breathlessness?1234567 QL6. Did you have sleepless nights because of your childs asthma?1234567 QL7. Were you bothered because your childs asthma interfered with family relationships?1234567 QL8. Were you awakened during the night because of your childs asthma?1234567 QL9. Did you feel angry that your child has asthma?1234567 (For interviewer to read(: During the past week, how worried or concerned were you: [Show response card] Very, Very Worried/ ConcernedVery Worried/ ConcernedFairly Worried/ ConcernedSomewhat Worried/ ConcernedA Little Worried/ ConcernedHardly Worried/ ConcernedNot Worried/ Concerned QL10. About your childs performance of normal daily activities?1234567 QL11. About your childs asthma medications and side effects?1234567 QL12. About being overprotective of your child?1234567 QL13. About your child being able to lead a normal life?1234567 QL14. Now, compared to this time last year, how has your family been dealing with [CHILDS] asthma? [Show response card] Much better now than one year ago 1 Somewhat better now than one year ago 2 About the same as one year ago 3 Somewhat worse now than one year ago 4 Much worse now than one year ago 5 SE1. Overall, how confident are you that you can control any asthma symptoms that your child has so that they dont interfere with the things he/she wants to do. Not at all confident 1 2 3 4 5 6 7 8 9 10 Totally confident SE2. Overall, how confident are you that you can control any asthma symptoms that your child has so that they dont interfere with the things your family wants to do. Not at all confident 1 2 3 4 5 6 7 8 9 10 Totally confident SECTION 6- HEALTH CARE UTILIZATION (For interviewer to read(: Now I would like you to also think about the past 12 months. I would like to ask you about hospitalization, emergency room visits, and visits to the doctor's office or clinic for asthma during that time. [Continue to show calendar] HC1. During the past 12 months, that is since _____________, did [CHILD] have to stay overnight in the hospital because of asthma? Yes...1 (If yes, how many times?_______ No.2 Dont Know 9 HC2. Not counting hospitalizations, during the past 12 months, that is, since _________, did [CHILD] go to an emergency room because of asthma? Yes...1 (If yes, how many visits? _______ No....2 Dont Know 9 HC3. Not counting hospitalizations or emergency room visits, during the past 3 months, that is, since _______________, did [CHILD] see a doctor or health care provider in the office or clinic for asthma? Yes 1 (If yes, how many visits? _______ No 2 HC3a. How many of these visits were unscheduled, that is, you walked in or scheduled less than 24 hours ahead? _______ (For interviewer to read(: Many people have problems making and keeping doctor's appointments for their child's asthma, because its hard to get to the clinic, they cant afford to go, or other reasons. HC4. In the past 12 months, have you had any problems making appointments for [CHILD]'s asthma? Yes... 1 No.. 2 SECTION 7 SMOKING (For interviewer to read(: Now Im going to ask you some questions about [CHILD]s exposure to tobacco smoke in your home and away from home. TS1. Did you smoke tobacco during the past 7 days? (1 Yes (2 No. (Skip to TS5 TS2. How many cigarettes did you smoke each day? _____ cigarettes [if not cigarettes, indicate (1 pipe or (2 cigar or (3 other _______________] TS3. On how many of the past 7 days did you smoke? _____ days TS4. When you smoked at home, how much of the time did you smoke inside the house as compared to going outside the house to smoke? Smoked outside the house: Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never (always smoked inside the house) 5 TS5. Please tell me if anyone else who lives in or regularly visits the house smokes in the home, and their relationship to [CHILD], such as father, grandmother, sibling, babysitter, family friend, and so forth. (Include all persons, and after each response, probe: Is there anyone else who smoked in the house in the past week? Record response in chart below): ( No one (Skip to TS6 Relationship: 1._____________________________________ 2. .____________________________________ 3. .____________________________________ 4. .____________________________________ 5. .____________________________________ TS5a. Do any of these people smoke inside the house most of the time? Yes (1 No (2 TS5b. If yes, how many? ____________________ TS6. Now think about places your child spends time AWAY from home. Does anyone smoke around your child? PlaceAmount smoked AWAY from homeIn a car (1 Every day (2 4-6 days/week (3 2-3 days/week (4 Once a week (5 Never At childcare (1 Every day (2 4-6 days/week (3 2-3 days/week (4 Once a week (5 Never At a friends (1 Every day (2 4-6 days/week (3 2-3 days/week (4 Once a week (5 Never Other (specify)  (1 Every day (2 4-6 days/week (3 2-3 days/week (4 Once a week (5 Never Other (specify)  (1 Every day (2 4-6 days/week (3 2-3 days/week (4 Once a week (5 Never  SECTION 8 ASTHMA HISTORY (ALLERGIES) (For interviewer to read(: Now I have another question about your childs asthma history. I would like you to think about the past three months and ask you a question about asthma attacks. Asthma attack refers to times when your childs asthma symptoms are worse, limiting his/her activity more than usual, or making you seek medical care for him/her. [Show calendar] AH4. During the past three months, about how many asthma attacks did [CHILD] have? ________ SECTION 9 MEDICATION (Interviewer: Now I would now like to find out about all medicines prescribed by a doctor that [CHILD] takes for his/her asthma. M1. In the past 12 months, has [Child] taken any medicines prescribed by a doctor for asthma?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No (Skip to M6 M2. Please SHOW me, one by one, all of the prescribed asthma medicines that [CHILD] has taken during the past 12 months. (If caregiver does not have medicines, ask him/her to describe each one and find it on the show card.) M2a. What is the name of the medicine?M2b. How is this medicine taken?M2c. How many days in the past 14 days (show calendar) did s/he take this medicine?M2d. How many times each day did he/she take this medicine? (Dose if inhaled steriods)M2e. Does [CHILD] use this medicine only at home, only at school, or both?M2f. Is this medicine mainly used to relieve symptoms as needed OR taken every day to control symptoms and prevent attacks?#1  FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)  FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know#2  FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)  FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know#3  FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)   FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know #4  FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)   FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know#5  FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)  FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know#6 FORMCHECKBOX 1 inhaler  FORMCHECKBOX 2 nebulizer  FORMCHECKBOX 3 nasal spray  FORMCHECKBOX 4 oral (pill/syrup)  FORMCHECKBOX 99 No longer used  FORMCHECKBOX 8 As needed  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Home only  FORMCHECKBOX 2 School only  FORMCHECKBOX 3 Both  FORMCHECKBOX 9 Dont know FORMCHECKBOX 1 Relieve symptoms  FORMCHECKBOX 2 Control asthma & prevent symptoms  FORMCHECKBOX 3 Other:________________  FORMCHECKBOX 9 Dont know Now, are there any other medicines prescribed by the doctor that you havent shown me? [Use the show card to help respondent identify any additional medications] Yes (1 [repeat questions above] No (2 [continue to next question] [After last medication identified by respondent, ask: Are there any more medications?] Yes (1 [repeat questions above] No (2 [continue to next question] M3. Does your child take medicines only when s/he was having signs or symptoms of asthma or even when s/he was not having symptoms, or both times (Circle one): Only for symptoms 1 Even when no symptoms .2 Both .3 M4. Has your child had any problems taking medications at school? Yes .1 (Specify____________________________________ No ...2 M6. Does [CHILD] have a spacer (such as an Aerochamber) to use with each of his/her inhalers? Yes 1 No 2 Does not have inhaler 3 Dont know 9 M7. In the past 14 days, when inhalers were used, how often did [CHILD] use his/her spacer? Never 1 Less than half the time 2 About half the time 3 More than half the time 4 Most/All the time 5 SECTION 10 - MEDICATION ADHERENCE (For interviewer to read(: Many families have problems making sure children get all of their asthma medications or making sure they get medicines on time. I am going to go over several types of problems and ask whether any of them have been hard for you: PH1. For many reasons, children do not always get their medicines exactly when they are supposed to. On a scale of 1 to 5, how many problems do you usually face when trying to be sure your child gets his/her medicines? 1 is no problems and 5 is a lot of problems with medicines: [Circle number below] 1 2 3 4 5 No problem A lot of problems PH2. On a scale of 1 to 5, how would you rate your child's experience with taking his/her medicines exactly on schedule? 1 means never missing a dose of medicine and 5 means often missing a dose: [Circle number below] 1 2 3 4 5 Never misses a dose Often misses a dose SECTION 11 - ASTHMA MONITORING (For interviewer to read(: Now I would like to ask you some questions about keeping track of [CHILD]s asthma: AM1. When was the last time you and/or [CHILD] were aware of or checked in on his/her asthma symptoms? [Ask as an open-ended question] In the past 2 weeks 1 In past 2 months 2 In past 6 months 3 In past 12 months 4 More than 12 months ago 5 AM2. Does [CHILD] now have a working peak flow meter? Yes 1 No 2 (Skip to AM4 Dont Know 9 (Skip to AM4 AM3. In the past 12 months how often did you use the peak flow meter to try to measure [CHILDs] breathing when his/her asthma was getting worse, or when he/she was having an asthma attack? (use show card) Always 1 Almost always 2 Sometimes 3 Almost never 4 Never 5 AM4. Has your doctor or other health professional provided you with a written plan (action plan) to help you decide how to change [CHILD]'s asthma medicine in response to changes in his/her asthma? Yes 1 No 2 (Skip to Section 14 Dont Know 9 (Skip to Section 14 AM5. In the past 12 months how often did you use the action plan to change [CHILDS] medicine in response to changes in his/her asthma? [use show card] Always 1 Almost always 2 Sometimes 3 Almost never 4 Never 5 AM6. Does your child's school or daycare have a copy of the action plan? Yes 1 No 2 Not in school or daycare 3 Don't know 9 AM7. Do all your child's regular caretakers and child health care providers have a copy of the action plan? Yes 1 No 2 No other regular caretakers and not in daycare 3 Don't know.9 SECTION 12 METERED DOSE INHALER USE, ABILITIES [If child does not use an inhaler, skip to Section 15] (For interviewer to read(: Now, Id like to watch [CHILD] use his/her inhaler. Please show me how you use the inhaler. [This test can be performed with a Placebo inhaler if child does not have one at the moment] Desirable Behaviors: Yes No N/A a. Patient shakes canister for 5 seconds. 1 0 98 b. Patient attaches spacer or Inspirease bag correctly. 1 0 98 c. Patient positions finger on the top of the medication canister and provides support. 1 0 98 d. Patient places the spacer tube or mouthpiece into the mouth between the teeth. 1 0 98 e. Patient exhales normally. 1 0 98 f. Patient closes lips around the spacer tube or mouthpiece. 1 0 98 g. Patient correctly presses down the top of the medication canister to release the medication. 1 0 98 h. Patient inhales medication deeply and slowly. 1 0 98 i. Patient holds the medication inside the lungs a minimum of 3 seconds before exhaling . 1 0 98 SECTION 13 - PEAK FLOW METER USE ABILITIES (For interviewer to read(: Has the child ever used a peak flow meter? (1 Yes (2 No If yes, continue. If no, skip to Section 16. (For interviewer to read(: Now Id like to see how you use a peak flow meter. Please show me how you use the peak flow meter: [provide child with the Mini-Wright meter] Yes No a. Stand up straight. 1 0 b. Make sure the arrow on the peak flow meter is at the 0 L/MIN position. 1 0 c. Take a deep breath. 1 0 d. Place mouthpiece behind your front teeth and seal your lips around the mouthpiece. 1 0 e. Blow fast and hard into the peak flow meter. 1 0 f. Read the number next to the arrow correctly. 1 0 Exit Home Environmental Checklist (HEC) Interviewer: for this questionnaire, the methods of getting information are: O = observation only, A = ask client, A+O = ask and observe A. PARTICIPANT ACTIONS I will now ask you some questions about things some people do in their homes to help control asthma triggers. There is no right or wrong answer, just tell me what YOU do. Now please tell me some things you do to: None 0Dont know 9B1. Lower exposure to dust mites B2. Keep roaches out of your home B3. Keep rodents (mice and rats) out of your home B4. Keep mold and moisture out of your home  B5. Keep pets from making your childs asthma worse B6. Keep pollens from making your childs asthma worse  B. DUST AND CLEANING (For interviewer to read(: Next, I would like to ask you some questions related to dust, cleaning, and washing. D1. When people come into your house, do they always: O + A a. Remove their shoes?  FORMCHECKBOX  1 Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  3 Sometimes b. Use doormat or hall rug to wipe their feet?  FORMCHECKBOX  1 Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  3 Sometimes D2. Do you now have a working vacuum cleaner in the house? O + A Yes..1 Brand:__________________________ Model#:______________________ Bag:_________________ No 2 (Skip to D5 D3. Does the vacuum have a special air filter, such as a HEPA filter, to keep dust in the vacuum? O  FORMCHECKBOX  1 Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  9 Dont know (For interviewer to read(: The next questions are about things you did to clean your house during the last 14 days. [None = 0, DK = 9].  During the LAST 14 DAYS, how many times did you or anyone in the home Times / 14 days_ A D4. Vacuum the floor of the room in which [CHILD] sleeps? #__________ A D5. Vacuum or wash the cloth-covered furniture in the home? #__________ [if no cloth covered furniture, enter 98] A D6. Dust the room in which [CHILD] sleeps? #__________ During the LAST 14 DAYS, how many times did you or any one in the home Times / 14 days_ A D10. Wash or freeze your child's stuffed animals? # __________ [If no stuffed animal, enter 98] A D11. Wash your childs sheets and pillowcases? # __________ [If no pillows, enter 98] A D12. Wash your childs pillows? #__________  A D13 Where do you usually do your laundry? At home 1 In another home 2 In a Laundromat 3 Other 4  A D14. When you wash [CHILD]'s sheets and pillow cases what temperature do you use for the (Circle number) a. Wash cycle? b. Rinse cycle? Hot 1.1 Warm 2.2 Cold 3.3 Dont Know 9.9 (For interviewer to read(: During the last 12 months, how many times did you: A D15. Wash the cover on your childs bed (i.e. blankets/spreads/ comforters)? Number of times #_______ Other 98 (Specify____________________________ Dont know99 C. VENTILATION AND MOISTURE (For interviewer to read(: Next are some questions about ventilation and moisture in your home. E1. First, how often do windows other than bathroom and kitchen fog up? Would you say: A (Read responses) Never 5 Rarely 4 Sometimes 3 Most of the time 2 Always 1 Dont Know 9 E2. Does the bathroom window or mirror stay fogged up for more than 15 minutes A after the shower is used?  FORMCHECKBOX  1 Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  9 Dont know E3. Do you use a humidifier/vaporizer in the home? A + O  FORMCHECKBOX  1 Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  9 Dont know D. PETS AND PESTS (For interviewer to read(: Next I would like to ask you some questions about pets. F1. Do you have any pets, such as dogs, cats, rabbits, birds, hamsters/gerbils/other rodents or others? Does it/Do they come inside? ________________________ Does it/Do they come inside the childs sleeping room? ______________ (For interviewer to read(: Next I would like to ask you some questions about cockroaches, and mice or rats. F2. Do you have cockroaches in your home now?  FORMCHECKBOX 1Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  9 Don't Know A If yes, has anything been done about it? __________________________ F3. Have you had any problems with mice or rats in your home now?  FORMCHECKBOX 1Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  9 Don't Know A If yes, has anything been done about it? __________________________ HOME WALK-THROUGH  (For interviewer to read( Now I would like to walk through several rooms of your home with you. I will be making observations, looking under the kitchen and bathroom sinks, and recording information about these rooms. I will also be asking you questions related to specific items in some of the rooms we will be in. Is it okay to start with your childs bedroom? E. CHILDS BEDROOM/SLEEPING AREA  G1. At what temperature do you keep this room during the heating season? ________ 0F (Enter 98 if the heater does not work) G2. Does the object (bed, mattress, etc.) on which [CHILD] usually sleeps have a zippered allergy control cover?   FORMCHECKBOX 1Yes  FORMCHECKBOX  2 No G3. Does the pillow have a zippered allergy control cover?  FORMCHECKBOX 1Yes  FORMCHECKBOX  2 No  FORMCHECKBOX  3 No pillow Interviewer: Please complete the HOME ASSESSMENT CHECK LIST for childs bedroom/sleeping area. All questions are O except where ASK is stated. Childs BedroomMark Correct Answer Type of floor covering:  FORMCHECKBOX 1 Carpeting  FORMCHECKBOX 2 Hardwood, tile, linoleum or vinyl  FORMCHECKBOX 3 Other Carpet type:  FORMCHECKBOX 1Level loop  FORMCHECKBOX 2 Shag or plush Is the carpet damp to touch? (If yes, ask: more than 48 hours? FORMCHECKBOX 1 Yes  FORMCHECKBOX 2No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2No Cloth-covered furniture? (If yes, how many pieces? FORMCHECKBOX  1Yes  FORMCHECKBOX 2 No #_____________Stuffed toys? (If yes, how many toys? FORMCHECKBOX 1 Yes  FORMCHECKBOX 2No #_____________Can at least one window be opened?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No Ask: When weather allows, do you open the window to ventilate?  FORMCHECKBOX 1 Always  FORMCHECKBOX 2 Most times  FORMCHECKBOX 3 Sometimes  FORMCHECKBOX 4 Never Types of window covering:  FORMCHECKBOX 1 Curtains/drapes  FORMCHECKBOX 2 Blinds or shades  FORMCHECKBOX 3 Not applicable Childs BedroomMark Correct AnswerLevel of dust on surface in the room  FORMCHECKBOX 1 None  FORMCHECKBOX 2 Slight  FORMCHECKBOX  3Moderate  FORMCHECKBOX 4 Heavy Structural problems Cracks (larger than thickness of a dime) Holes Peeling paint Other (If yes, specify:  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No _______________________(If any structural problems, mold or leak, ask: Have you tried to fix the problem yourself? (If yes, what did you do? Have you asked your landlord to fix the problem? (If yes, what did he/she do?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  Childs BedroomMark Correct AnswerAre any of the following odors present? Tobacco Mold Fragrance (air freshener) Candles/incense Strong smelling cleaner or chemical Other  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No: __________________(If yes, specify below ___________________________ See evidence of (in the room and closet) Water damage Condensation Water leaks/drips Water leak source  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Outside  FORMCHECKBOX 2 Inside See evidence of (in the room and closet) Mold/mildew Location  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No (If yes, record items below ________________________________________________ _________________________________________________ Intensity  FORMCHECKBOX 1 ( 10 ft2  FORMCHECKBOX 1 Slight  FORMCHECKBOX 2 (10 ft2  FORMCHECKBOX 2 Moderate  FORMCHECKBOX 3 Severe  See evidence of (in the room and closet) Cockroaches (include eggs, feces, insects) Rodents (or droppings) Cigarette butts, ashtrays with ashes  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No F. LIVING ROOM/FAMILY ROOM (For interviewer to read( Next, let's have a look at the living room. Please complete the HOME ASSESSMENT CHECK LIST for the living room or family room. Living Room/Family RoomMark Correct AnswerCloth-covered furniture? (If yes, how many pieces? FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No #_____________Level of dust on surface in the room FORMCHECKBOX 1 None  FORMCHECKBOX 2 Slight  FORMCHECKBOX 3 Moderate  FORMCHECKBOX 4 HeavyCan at least one window be opened?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No Ask: When weather allows, do you open the window to ventilate?  FORMCHECKBOX 1 Always  FORMCHECKBOX 2 Most times  FORMCHECKBOX 3 Sometimes  FORMCHECKBOX 4 Never  G. the KITCHEN (For interviewer to read(: Next, lets have a look at the kitchen. I2a. Is the hood or vent over the stove ventilated to the outside?  [Look at outside wall if possible to see if vent is in place.]  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 9 Dont know I2b. How often is the fan or vent used when the stove is in use? Would you say:  Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 Dont Know 9  I2c. Do the toilet paper test: Is the suction in the fan adequate?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 9 Dont know  Please complete the home assessment CHECKLIST for the kitchen. KitchenMark Correct AnswerCan at least one window be opened?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No Ask: When weather allows, do you open the window to ventilate?  FORMCHECKBOX 1 Always  FORMCHECKBOX 2 Most times  FORMCHECKBOX 3 Sometimes  FORMCHECKBOX 4 Never  Are any of the following odors present? Tobacco Mold Fragrance (air freshener) Candles/incense Strong smelling cleaner or chemical Other  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No: __________________(If yes, specify below ___________________________ See evidence of (in the room and closet) Mold/mildew Location  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No (If yes, record items below ________________________________________________ _________________________________________________ Intensity  FORMCHECKBOX 1 ( 10 ft2  FORMCHECKBOX 1 Slight  FORMCHECKBOX 2 (10 ft2  FORMCHECKBOX 2 Moderate  FORMCHECKBOX 3 Severe See evidence of (in the room and closet) Cockroaches (include eggs, feces, insects) Rodents (or droppings) Cigarette butts, ashtrays with ashes  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No H. THE BATHROOM (For interviewer to read( Lets visit the bathroom [CHILD] uses most J1. Is there a working fan in the bathroom? [Turn on the fan to test]  Yes ..1 No ..2 (Skip to Bathroom Checklist J1a. (If yes, how often is the fan used during and after a shower? Would you say:  Always 1 Most of the time 2 Sometimes 3 Rarely 4 Never 5 Dont Know 9 J1b. Do the toilet paper test: Is the suction in the fan adequate?   FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No J1c. Is the fan vented to the outside? [Check outside to see if vent is visible]   FORMCHECKBOX 1Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 3 Dont know  Please complete the home assessment CHECKLIST for the bathroom. BathroomMark Correct AnswerCan at least one window be opened?  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No Ask: When weather allows, do you open the window to ventilate?  FORMCHECKBOX 1 Always  FORMCHECKBOX 2 Most times  FORMCHECKBOX 3 Sometimes  FORMCHECKBOX 4 Never Are any of the following odors present? Tobacco Mold Fragrance (air freshener) Candles/incense Strong smelling cleaner or chemical Other  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No: __________________(If yes, specify below ___________________________ See evidence of (in the room and closet) Mold/mildew Location  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No (If yes, record items below ________________________________________________ _________________________________________________ Intensity  FORMCHECKBOX 1 ( 10 ft2  FORMCHECKBOX 1 Slight  FORMCHECKBOX 2 (10 ft2  FORMCHECKBOX 2 Moderate  FORMCHECKBOX 3 Severe  I. HEAT SOURCE [Use the table below to record answers] (For interviewer to read(: Next, I would like to ask you some questions about the heat sources in your home. A + O questions to the rightL1. Filter on air intake A + O L1a. How clean? O1a. Electric furnace  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 3 Dont know FORMCHECKBOX 1 Clean  FORMCHECKBOX 2 Partially dirty  FORMCHECKBOX 3 Dirty  FORMCHECKBOX 4 Unable to observe b. Gas  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 3 Dont know FORMCHECKBOX 1 Clean  FORMCHECKBOX 2 Partially dirty  FORMCHECKBOX 3 Dirty  FORMCHECKBOX 4 Unable to observec. Oil  FORMCHECKBOX 1Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 3 Dont know FORMCHECKBOX 1 Clean  FORMCHECKBOX 2 Partially dirty  FORMCHECKBOX 3 Dirty  FORMCHECKBOX 4 Unable to observed. Wood stove fireplacee. Electric baseboard J. OTHER (For interviewer to read(: Now, some other questions. M1. Do you have a working clothes dryer in the home?  Yes 1 No 2 (Skip to N1 M1a. Is it vented on the outside? (Check on outside wall to see if there is a vent)  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No  FORMCHECKBOX 3 Dont know K. CHEMICALS AND IRRITANTS N1. Do you have anything in your home that has a strong odor or that irritates your childs asthma or makes the asthma worse, such as: a. Cleaning products that contain bleach or ammonia  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No b. Paint products, solvents, glue  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No c. Air fresheners, scented candles, incense  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No d. Pesticides (Dont make asthma worse but are toxic)  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2 No e. Other: ________________________  FORMCHECKBOX 1 Yes  FORMCHECKBOX 2No Specify (For interviewer to read(: This concludes our interview. I want to thank you for participating in this project and want you to know that the information and opinions that you have given us about your childs asthma will help to improve asthma care for many others. Thank you for taking the time to meet with me today. 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