Interviewer__________ Household ID___________ Participant ID ___________ Date _____________ Start time _____________ End time ______________ Participant Name: ______________________________________________________ SECTION I: ACE ADULT SURVEY General Survey Module A: Location/Exposure I would like to begin by showing you a map of the areas affected by [Description of Incident] on [Date]. The affected areas are highlighted. From now on, I will refer to the [Description of Incident] on [Date] as “the incident.” After reviewing a map of the exposed area(s), ask respondents the following questions: Were you in this area at any time between [Incident Date/Time] and [End Date/Time]? Yes No Say to the respondent: Thank you for your time. Record the end time and do not ask any further questions. This person is not eligible for the survey. I would like to know about each place you went within the highlighted area on the map between [Incident Date] at [Time] and [End Date/Time] so that I can construct a timeline and understand what happened when you were exposed. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location. Location 1: Location 2: Location 3: What is the address of where you (first/next) were during the incident? Probe for as much location information as possible. Then, continue to b. Do not ask about all locations first. Collect all
Interviewer__________ Household ID___________ Participant ID ___________ Date _____________ Start time _____________ End time ______________ Participant Name: ______________________________________________________ SECTION I: ACE ADULT SURVEY General Survey Module A: Location/Exposure I would like to begin by showing you a map of the areas affected by [Description of Incident] on [Date]. The affected areas are highlighted. From now on, I will refer to the [Description of Incident] on [Date] as “the incident.” After reviewing a map of the exposed area(s), ask respondents the following questions: Were you in this area at any time between [Incident Date/Time] and [End Date/Time]? Yes No Say to the respondent: Thank you for your time. Record the end time and do not ask any further questions. This person is not eligible for the survey. I would like to know about each place you went within the highlighted area on the map between [Incident Date] at [Time] and [End Date/Time] so that I can construct a timeline and understand what happened when you were exposed. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location. Location 1: Location 2: Location 3: What is the address of where you (first/next) were during the incident? Probe for as much location information as possible. Then, continue to b. Do not ask about all locations first. Collect all
ACE_General_Survey.docx