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3~ <br />Mill Creels Road Area Survey -Question-by-Question Sheet <br />1. DATE <br />Record the date interview is conducted, <br />Data Entry Format: MM/DD/YYYY <br />2. PROPERTY TMBL <br />This section of the survey will be pre-filled. Do not write in this area. <br />2A. PROPERTY ADDRESS <br />This section of the survey will be pre-filled. Do not write in this area. <br />2B. TELEPHONE <br />This section of the survey will be pre-filled, Do not write in this area, <br />3. PROPERTY OWNER <br />This section of the survey will be pi°e-filled Do not write in this area. <br />4. INTERVIEWER <br />Record YOUR First Name and Last Name <br />5. TIME OF INTERVIEW ATTEMPTED <br />Record time interview is conducted <br />6. DO YOU LIVE AT THIS ADDRESS? <br />Select YES or NO based on the response. <br />If no, request the name and telephone number of the person who lives at this address, <br />(Terminate telephone call at this point -see D. Special Instnrctions) <br />Contact person who lives at this address and continue to use the same survey <br />7. WHAT IS YOUR FIRST NAME? <br />Ask and record interviewee's first name. <br />8. WHAT IS YOUR LAST NAME? <br />Aslc and record interv'iewee's last name <br />9. WHAT IS YOUR COMPLETE ADDRESS? <br />This information will be pre-filled. Ask interviewee to confirm their full address (house number, <br />street name, city, and zip code), Record any changes in the appropriate fields.. <br />10. HOW MANY FULL TIME or PERMANENT RESIDENTS ARE THERE IN YOUR <br />HOUSEHOLD? <br />Record the number of people who live in the home year round. Ask interviewee to include those <br />who spend six or more months at this residence. <br />Question E~lanation: The Health Department is interested in this information to help determine <br />whether any diagnosed cancers may be related to environmental exposures over time <br />Data Entry Format: 001 <br />Page 28 of 47 <br />