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~i <br />11. IN WHAT YEAR WAS THIS HOUSE BUILT? <br />Record the year the house was built. <br />Data Entr~yFo~mat: YYYY <br />12. DOES THIS HOME HAVE A WELL? <br />Select YES or NO based on response. <br />13. HOW LONG HAS YOUR FAMILY LIVED AT THIS ADDRESS? <br />Record the number of years (or months) family has lived at address. <br />Special Instructions: If the family has lived at the address for less than S years, go to the next <br />question.. If the family has lived at the address for more than S years, skip to Question 1S, <br />14. WHERE DID YOU LIVE BEFORE MOVING INTO THIS HOUSE? <br />Aslc interviewee to provide complete addresses (house number, street name, city, and zip code) <br />of their last five residences and the number of years lived at each residence. Record this <br />information in the appropriate fields. <br />COMMENTS <br />Record any additional comments stated by the interviewee. <br />Cancer History <br />Speciat Instructions: Explain that you will now be asking questions related to cancer diagnosis <br />within the household. <br />15. HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN DIAGNOSED <br />WITH CANCER? <br />Select YES or NO based on the response, <br />~ecial Instructions: If response is no, end the interview. Thank interviewee for their time <br />and for the information provided. Explain that the necessary information has been collected <br />and that the Orange County Health Department will collect similar data from other residents. <br />Explain that general findings will be shared with the community. If the interviewee says yes, <br />go to the next question. If more than one person in household has had cancer, use_a <br />separate survey. for each diagnosed person and clip all surveys together. <br />16. WHAT IS YOUR RELATIONSHIP TO THE PERSON WITH CANCER? <br />Select the appropriate response or prompt interviewee with the following choices: self; spouse, <br />child, parent, sibling, other, or no relation. <br />SPPcial Instructions: If interviewee says self, skip to Question 24. If interviewee says <br />child, aslc if the child is under 18 years of age. If the child is under 18 years, a parent or <br />guardian should be interviewed. If parent/guardian not available, determine call back <br />date/time. Stop interview here and document call back info at upper right of is` page. <br />Page 29 of 47 <br />