1.1 What are the ages of all the people who live here, including children?

 

________, _________, ________, ________, ________, ________, _________

 

 

1.2. Do you have any type of health problem diagnosed by a doctor?

 

 

Age	Health Problem

 

1.3. Have you been previously visited to receive information or supplies regarding pesticides and your health?

a)      Yes,  who visited you _____________________________

b)      No

c)      No not remember

 

 SecTION 2. Knowledge on pesticides

 

2.1. Do you know what the word pest means?

a)      Yes, what? _____________________________

b)      No

c)      Do not remember

 

2.2. Do you know what the word plague means?

a)   Yes, what? _____________________________

b)   No

d)      Do not remember

 

 

2.3. What do you understand when you hear the word pesticide?

a)  ____________________________________

b) Do not remember

c) No not know

 

2.4. Can you tell me other names given to the products used for controlling pests/plagues?

a)  ____________________________________

b) Do not remember

c) Do not know

 

2.5. Do you know if pesticides/poisons can cause health problems?

a) Yes, like which ones? ___________________________________________

b) No

 

2.6. Do know how pesticides/poisons can enter your body?

a) Yes, how? ____________________________________________________

b) No

 

2.7. Do you know why children are at higher risks?

a) Yes, why? _____________________________________________________

b) No

 

2.8. Do you know what to do to protect your children from pesticides and poisons?

a) Yes, what? ______________________________________________________

b) No

 

2.9. Do you know the symptoms of poisoning by pesticides/poisons?

a) Yes, which ones? __________________________________________________

b) No

 

2.10. Do you know what to do in case of poisoning by pesticides/poisons?

a) Yes, what? ________________________________________________________

b) No

 

2.11. Do you know of a home remedy to fight or prevent plagues?

a) Yes, which one? ____________________________________________________

b) No

 

2.12. Have you used it in your home?

a) Yes

b) No

 

SECTION 3. Use of Pesticides inside your home

 

3.1. Is there a hole in the window/window screens or in the walls that can be the entrance of insects, or mice to the house?

a) Yes

b) No

 

3.2. Do you use pesticides/poisons inside your house?

a) Yes

b) No (go to P # 3.8)

 

3.3 Can you tell me what kind of products you use and how often?

Pest	Type of  product (eraser, spray, powder)	Name of product	Times of year that is used
			Spring and   Summer	Fall and Winter
Ants
Cockroaches
Flies, mosquitoes
Mice, rats
Others: _________________

 

3.4. How often do you use protection equipment (gloves, goggles, long sleeve shirts) when applying pesticides/poisons inside your home?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

3.5. How often do you keep the pesticides in their original containers and tightly closed?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

3.6. Are the pesticides/poisons away fro the reach of children?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

3.7. Are the children present when pesticides/poisons are applied inside your home?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

3.8 Do you have the number of the Poison Control Center close to your phone?

a) Yes

b) No

SECTION 4. use of pesticides outside your home

 

4.1. Do you use pesticides/poisons outside your home?

a) Yes

b) No (go to P # 4.8)

 

4.2. Can you tell me what products you use and how often?

 

Pest	Type of  product (eraser, spray, powder)		Name of  product		Times of year that is used
					Spring and Summer	Fall and Winter

 

4.3. How often do you use protection equipment (gloves, goggles, long sleeve shirts) when applying pesticides/poisons outside your home?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

4.4. How often do you keep the pesticides in their original containers and tightly closed?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

4.5. Are the pesticides/poisons away from the reach of children?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

4.6. Are the children present when pesticides/poisons are applied outside your home?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

4.7. Do you apply pesticides/poisons in the children’s play area?

a) Yes

b) No

 

4.8. Do you use mosquito repellent on children?

a) Yes

b) No

 

Section 5. use of agricultural pesticides

 

5.1. Is there someone living in the home that works out in the agricultural fields?

a) Yes

b) No (go to P # 6.1)

 

5.2. Do you know if out in the field they read the labels and follow the instructions when applying the pesticides/poisons?

a) Yes

b) No

c) Do not know

 

5.3. The person(s) that work out in the field, use protection equipment (gloves, goggles, long sleeve shirts) when applying pesticides/poisons?

a) Yes

b) No

c) Do not know

 

5.4. The person(s) that work out in the field, wash their hands before eating, drinking, and smoking during their working times?

a) Yes

b) No

c) Do not know

 

5.5. The person(s) that work out in the field, leave their shoes outside when getting home?

a) Yes

b) No

c) Do not know

 

5.6 The person(s) that work out in the field, take showers and change clothes as soon as they get home?

a) Yes

b) No

c) Do not know

 

5.7. Do you wash the clothes of the person working out in the field separately?

a) Yes

b) No

c) Do not know

 

5.8. The person(s) working out in the filed ever bring pesticides from the field home?

a) Yes

b) No

c) Do not know

 

5.9. The person(s) working out in the filed ever bring empty containers from the field home?

a) Yes

b) No

c) Do not know

 

5.10. The person(s) working out in the filed, know the protection measures for agricultural workers (WPS)?

a) Yes

b) No

c) Do not know

 

Section 6. Other related topics

 

6.1. Are there any places in your home that are moldy or are constantly humid or wet?

a) Yes

b) No

c) Do not know

 

6.2. Has the house ever had any floods, leaking, or indoor/outside dripping caused by drainpipes, septic tanks, or other causes?

a) Yes

b) No

c) Do not know

 

6.3. Do you have more than ten plants inside your home?

a) Yes

b) No

 

6.4. Do you have any pets?

a) Yes

b) No (go to P # 6.8)

 

6.5 How often do you let your pets be inside the house?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

6.6. Do your pets wear any collars or other products used for controlling ticks or fleas?

a) Yes

b) No

c) Do not know

 

6.7. Is your pet’s food closed during the night?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

6.8. How often do you mop the floors?

a) Daily

b) 2-3 times per week

c) 1 time per week

d) 2 times per month

e) 1 time per month

f) Other _____________________________

 

6.9. How often do you clean with a wet cloth your furniture, shelves, and window corners?

a) Daily

b) 2-3 times per week

c) 1 time per week

d) 2 times per month

e) 1 time per month

f) Other _____________________________

 

6.10. Do you carry out a profound cleaning at least two times a year (including carpet cleaning, curtain cleaning, lamps, and replacements of old tapestries)?

a) Yes

b) No

 

6.11. Is the food kept away in closed containers?

a) Always

b) Almost always

c) Sometimes

d) Almost never

e) Never

 

6.12. Do you keep your trash container close?

a) Yes

b) No

 

6.13. How often do you take the trash out to the trash container?

a) Daily

b) 2-3 times per week

c) 1 time per week

d) Other _____________________________

 

 

READ: Thank you very much for your answers. Now we will give you some information materials and a “healthy kit I” and we will demonstrate how to use the items in it. If you agree, we will schedule a second visit four or five weeks from now. This visit is to hear your comments and opinions about you practicing the recommendations. We will also ask you about the helpfulness of the materials and items from the Kit, and will provide more products in the “healthy kit II”.

 

Section 7. Summary of visit

 

Day and time of second visit: ___________________________

                                   

Summary of the most important recommended actions that will be checked and will be taken care of during the next visit:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Time the Interview Ends: ____________