Document ppzaMJ95XGvz80p8kELNd3YzD

Study ID Number _ _ _ __ Name _ _ __ OE3 _ Agricultural Chemicals and agricultural products [J no [J yes [J do not know If yes, please check them below 1 _ Fungicides, esp. 1.1 _ Dithiocarbamates (used as fungicides) 2 _ Insecticides, esp.2.1 _ Organic phosphates or2.2 _ Carbamates 3 _ Herbicides, esp.3.1 _ Chloro phenoxy acetic acids (2,4,D or 2,4,5 T) 4 _ Other thiocarbamate pesticide uses 5 _ Fertilizers (especially inorganic nitrogen fertilizers) 6 _ Wood preserves 7 _ Leather, or leather dust 8 Wood or wood dust Chemicals/products Times per week Duration (hours/week) Date of exposure Min Max Typical From to l. 2. 3. I = almost every day, 2 = more than 3 tImes per week, 3 = I to 2 times a week, 4 = less than one time a week OED3 Describe your exposure OE4 - Other substances [J no [J yes [J do not know If yes, please check them below 1. _ Paints, varnishes, lacquers, wood stains 2.1 _ Diesel engine exhaust or 2.2 _ Gasoline engine exhaust 3 _ Glues, adhesives or mastics used to fasten objects together 4 _ Epoxy resin glues or coatings (e.g., two-part epoxy paints) 5 _ Styrene, or styrene containing plastics, esp. styrene-butadiene "rubber" 6 _ Inks or pigments used for coloring paints, fabrics or other materials 7 _ Hair dyes or other dyes 8 _ Vinyl chloride (in making PVC, synthetiC "rubber" or organic chemical manufacturing) 9 - Carbamates or 10. _ Dithiocarbamates used in ways other than as pesticides (including synthetiC rubber manufacturing) 11 _ Fumigants and sterilizing agents in general 12 _ Ethylene oxide 13 _ Formaldehyde (or formalin used as a leather preservative or embalming fluid), or possibly in industries such as ink, synthetiC rubber, adhesive, photographic film, furniture manufacturing, or the textile industry 14 _ Phenols or chlorophenols (e.g., pentachlorophenol) 15 - Chlorine 16 _ Ionizing radiation, X-rays 17 - Microwaves 18 Electromagnetic fields Chemicals l. Times per week Duration (hours/week) Min Max Typical II Date of exposure From to I Version 24 February 2004 CC_DP Questionnaire 11 of 15 SH ELL-MCCLU RG-059289