Exposure and Health Survey

 

NEW YORK STATE DEPARTMENT OF HEALTH

Exposure and Health Survey

Long Island, NY

 

Information
Gender
Current Residential Address

Mailing Address (if different)

Questions
1_1. What was/is the address of the home served by Long Island public water supply where you lived most recently?
Address
1_2. What was/is the address of the home served by Long Island public water supply where you lived the longest?
Address

2. Please list all the years that you lived in a home served by the Long Island public water supply. (e.g. 1996 to 2016)

Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)

The next questions are about the time BEFORE you knew about PFOS in the drinking water

3. During the time that you lived in a home served by the Long Island public water supply, how many 8 oz cups of water or beverages prepared with tap water did you drink per day?

4. During the time that you lived in a home served by the Long Island public water supply, did you filter the water?

5. During the time that you lived in a home served by the Long Island public water supply, did you drink bottled water at home?

6. Have you ever lived in a home served by a private well in Long Island?

6_1. What was/is the address of the home served by a private well in Long Island where you lived most recently?
Address
6_2. What was/is the address of the home served by a private well in Long Island where you lived the longest?
Address

7. Please list all the years that you lived in a home served by a private well in Long Island. (e.g. 1996 to 2016)

Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)
Years (e.g. 1996 to 2016)

The next questions are about the time BEFORE you knew about PFOS in the drinking water

8. During the time that you lived in a home served by a private well in Long Island, how many 8 oz. cups of water and beverages prepared with well water did you drink per day?

9. During the time that you lived in a home served by a private well in Long Island, did you filter the water?

10. During the time that you lived in a home served by a private well in Long Island, did you drink bottled water at home?

11. Have you ever attended a daycare or school in Long Island?

ADULTS ONLY: Questions about exposure to PFOS at work

(please cover a minimum of 20 years of work)

12. Have you ever worked at a manufacturing facility or factory within or outside Long Island?

IF YOU CURRENTLY OR PREVIOUSLY WORKED AT A MANUFACTURING FACILITY OR FACTORY, LIST JOB EXPERIENCE BELOW. ANY ADDITIONAL EXPERIENCES SHOULD BE LISTED IN THE SPACES PROVIDED BELOW.

15. What years did you work there? (e.g., 1996 to 2016)

Years (e.g. 1996 to 2016)

16. What is/was your job title and brief job duties?

18. Other manufacturing facility or factory job experience within or outside Long Island

Was PFOS used?
Was PFOS used?
Was PFOS used?
Was PFOS used?

19. Have you ever worked somewhere that was served by Long Island public water supply and you drank the water?

20. Have you ever worked somewhere in Long Island that was served by a private well and you drank the water?

21. Have you ever been a professional or volunteer firefighter?

21_1. If yes, dates:

22. Have you ever smoked cigarettes?

22_1. If current smoker, how many cigarettes per day/week/month (indicate day or week or month, and the number of cigarettes)?

Yes / No

If YES, tell what year

Circulatory

High blood pressure

High blood pressure title

Coronary artery disease

Coronary artery disease

High cholesterol

High cholesterol

Stroke

Stroke

Autoimmune

Lupus

Lupus

Type 1 diabetes

Type 1 diabetes

Inflammatory bowel disease

Inflammatory bowel disease

Ulcerative colitis

Ulcerative colitis

Crohn’s disease

Crohn’s disease

Multiple sclerosis

Multiple sclerosis

Rheumatoid arthritis

Rheumatoid arthritis

Other autoimmune

Yes / No

Liver

Hepatitis

Hepatitis

Enlarged liver

Enlarged liver

Fatty liver disease

Fatty liver disease

Cirrhosis

Cirrhosis

Other liver:

Neurological

Alzheimer’s disease

Alzheimer’s disease

Parkinson’s disease

Parkinson’s disease

AML – Lou Gehrig’s disease

AML – Lou Gehrig’s disease

Other neurological:

Yes / No

Thyroid

Hypothyroidism

Hypothyroidism

Hyperthyroidism

Hyperthyroidism

Other thyroid:

Yes / No

Kidney

Chronic kidney disease

Chronic kidney disease

End-stage renal disease

End-stage renal disease

Other kidney:

Yes / No

Pregnancy

Pregnancy induced hypertension

Pregnancy induced hypertension

Pre-eclampsia

Pre-eclampsia

Other pregnancy problem:

Yes / No

Cancer

Cancer type:

Yes / No

Cancer type:

Yes / No

Cancer type:

Yes / No
Other conditions
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