ML19331C995

Responds to Util Request for Guidance Re Proposed TMI Worker Registry.Worker Registry Dependent on Dosimeter Issuance & Medical Exam Info Should Include long-term Health Effects Followup.Recommends Worker Info Release Statements

ML19331C995
Person / Time
Site:	Crane
Issue date:	08/05/1980
From:	Jay Collins NRC - NRC THREE MILE ISLAND TASK FORCE
To:	Arnold R METROPOLITAN EDISON CO.
References
CON-NRC-TMI-80-121 NUDOCS 8008270037
Download: ML19331C995 (47)

Text

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DISTRIBUTION:,

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m POOR ORIGINALNm o 7.. TERA ? m...v. Office HQ a.

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' B. Sny J. Collins M C c WC N-M..Dincan,lA[' I '.,;'-t, N8'

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Docket No.: ~ 50-320

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Mr. R. C. Arnold-

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J. R. B'uchanan,.'NS'ICT ~

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Dear Mr. knold:

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This letter is in response to Metropolitan Edison's.recuest for guidanceis ?

l' in three specific' areas of th6 proposed TMI worker registry...The NRC'sr.

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• r technical staff has discussed these areas' with NIOSH, fiRC consult. ants, y... _ 'a., T l

and NRC's Office of the. Executive 1.egal Ofrector. w 1

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As a result of these discussions, we make th'e 'foll'owing re'comendations.:..* t

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Met-Ed's request #1: Clarification of 'which, THI %orker' groups are to be M..

included in the. worker registry. '

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,,i For purpose of the TMI worker registry, a worker shalli NRC_ staff respanse:

be defined as any person who has been issDed a~pers~onal. radiation dosimeterJ J. M -

28,5 979.i Therefore', inclusion [ini N W.

at the' TMI' nuclear. facility since March' 1

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the TMI worker registry should be based up9n whether'an individual.was T

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badged..not upon whether he was, a. nuclear. or horifnuclear ' worker. ' y

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Het-Ed's reg'uesi. f 2:' ' Guid'anci'on ~ data t' ~ lie ?in,clu.dedLin h..t.'! d,.

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y NRCstaffres)onse:. If Met-Ed implements a medical'~ examination" program S.M - i~f.

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e similar to the Department of the Navy's NAVMED P-5055.. all. the necessary j 'c-J.

baseline medical information should be obtained for the follow-up. for lo'ng - M.d

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. term health' effects.W~.

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At the time of the initial physical'yexamination; information on th;e individr W1..L Q,..

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ual's rnedical history, occupational history'and personal id'entifieri.should.'..

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.e recorded.

l 4 I are included for your guidance '(Enclosur4s l' and '2)f 0f 'particular. importancE '.,: >.

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ain the medical history is the information~o'n1th'e.fre'quen'cy,[' nam'unt,'and T N

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duration of tobacco use. A occupational' hist'o'ryh' including.

.' addresses of previous employsrs'and' previous? exposures to any: carcinogenic s ' S M ~

substances is ' vital for a '.long, term health' effects sthdy. ;To help insure..& " G '

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' the traceability of an in'dividual,'we also recornend that a' worker providei W W ~

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the names and addresses of r.everal next-of-kin.i n }$ }.s[#.% %

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ir. R. C. Arnold

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AUG 5 1330 s

Het-Ed's request #3: Develop.cnt of a form to be signed by a nuclear worker for release of personal information needed for the follow-up forJ long-term health effects in the nuclear power industry.

The fiRC staff recomends that a statement similar to -

NRC staff response:

the enclosed release of information statement (Enclosure 3) be, signed by. '

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a nuclear workerihen he begins work at the TMI site; -

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11e h' ope the above responses to your requests are adequate.

If there are :. ', W :;c';j

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.fJ additional questions, please contact us.

.s Sincerely,,

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Original cisned by

' John T. Collins John T. Collins Deputy Program Director TMI Program Office 7

Enclosures:

1.

NIOSH llealth Questionnaire

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2.

t:10SH llealth Questionnaire.

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3.

TMI Worker Registry Consent form

~cc:. Murray' Miles, BETA, Inc.

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Dick fleward.GPU s.

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m Jesse Brasher', Met-Ed' u

.I. E. Hildebrand,' Met-Ed

, Paul.Strudler HIOSH

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R C, Arnold Me, trop 311 tan Edison Company Mr. G. K. Hovey J. B. Lieberman, Esquire Director, Unit 2 Berlock, Israel, Lieberman Metropolitan Edison Company 26 Broadway P. O. Box 480 New York, NY 10004 Middletown, PA 17057 George F. Trowbridge, Esquire Mr. J. J. Barton Shaw, Pittman, Potts & Trowbridge Manager, Site Operations, Unit 2 1800 M Street, N.W.

Metropolitan Edison Company Washington, DC 20036 P. O. Box 480 Middletown, PA 17057 Ms. Mary V. Southard, Chairperson Citizens for a Safe Environment Mr. J. W. Brasher P. O. Box 405 Manager, Radiological Control, Unit 2 Harrisburg, PA 17108 Metropolitan Edison Company P. O. Box 480 Dr. Walter H. Jordan Middletown, PA 17057 881 W. Outer Drive Oak Ridge, TN 37830 Mr. B. Elam Manager, Plant Engineering, Unit 2 Dr. Linda W. Little Metropolitan Edison Company 5000 Hermitage Drive P. O. Box 480 Raleigh, NC 27612 Middletown, PA 17057 Karin W. Carter, Esquire Mr. R. F. Wilson 505 Executive House Director, Technical Functions P. O. Box 2357 Metropolitan Edison Company Harrisburg, PA 17120 P.O. Box 480 Middletown, PA 17057 Honorable Mark Cohen 512 E-3 Main Capital Building Mr. L. W. Harding Harrisburg, PA 17120 Supervisor of Licensing Metropolitan Edison Company Ellyn Weiss, Esquire P. O. Box 480 Sheldon, Harmon, Roisman & Weiss Middletown, PA 17057 1725 I Street, N.W., Suite 506 Washington, DC 20000 Mr. E. G. Wallace Licensing Manager Mr. Steven C. Sholly GPU Service Corporation 304 S. Market Street 100 Interpace Parkway Mechanicsburg, PA 17055 Parsippany, NJ 07054 Mr. Thomas Gerusky Mr. I. R. Finfrock, Jr.

Bureau of Radiation Protection Jersey Central Power & Light Company P. O. Box 2063 Madison Avenue at Punch Bowl Road Harrisburg, PA 17120 Morristown, NJ 07950 Mr. Marvin I. Lewis Mr. R. W. Conrad 6504 Bradford Terrace Pennsylvania Electric Company.

Philadelphia, PA 19149 1007 Broad Street Johnstown, PA 15907 i

Ms. Jane Lee R. D. 3, Box 3521 Etters, PA 17319 s

I Nr. R. C. Arnold Metropolitan Edison Company Walter W. Cohen, Consumer Advocate Ms. Kathy McCaughin Department of Justice Three Mile Island Alert, Inc.

Strawberry Square,14th Floor 23 South 21st Street Harrisburg,.PA 17127 Harrisburg, PA 17104 Robert L. Knupp, Esquire Ms. Marjorie M. Aamodt Assistant Solicitor R. D. #5 Knupp and Andrews Coatesville, PA 19320 P. O. Box P 407 N. Front Street Ms. Karen Sheldon Harrisburg, PA 17108 Sheldon, Harmon, Roisman & Weiss 1725 I Street, N.W., Suite 506 John E. Minnich, Chairperson Washington, DC 20006 Dauphin Co. Board of Commissioners Dauphin County Courthouse Earl B. Hoffman -

Front and Market Streets Dauphin County Consnissioner Harrisburg, PA 17101 Dauph% County Courthouse Front and Market Street Robert Q. Pollard Harrisburg, PA 17101 Chesapeak Energy Alliance 609 Montpelier Street Government Publications Section Baltimore, MD 21218-State of Library of Pennsylvania Box 1601 Education Building Chauncey Kepford Harrisburg, PA 17127 Judith H. Johnsrud Environmental Coalition on Nuclear Power Dr. Edward O. Swartz 433 Orlando Avenue Board of Supervisors State College, PA 16801 L

'-.derry Township RL Geyers Church Road Ms. Frieda Berryhill, Chairperson Midtletown, PA 17057 1

Coalition for Nuclear Power Plant Postponement U. S. Environmental Protection Agency 2610 Grendon Drive Region III Office Wilmington, DE 19808 ATTN:

EIS C0ORDINATOR Curtis Building (Sixth Floor)

Holly S. Keck 6th and Walnut Streets Anti-Nuclear Group Representing York Philadelphia, PA 19106 245 W. Philadelphia Street York, PA 17404 Dauphin County Office Emergency Preparedness John Levin, Esquire Court House, Room 7 Pennsylvania Pdblic Utilities Conunission Front and Market Streets P. O. Box 3265 Harrisburg, PA 17101 Harrisburg, PA 17120 Department of Enviornmental Resources Jordon D. Cunningham, Esquire ATTN:

Director, Office of Fox, Farr and Cunningham Radiological Health 2320 H. Second Street

' P. O. Box 2063 Harrisburg, PA 17110 lHarrisburg,PA 17105 i

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i Mr. R. C. Arnold Metropolitan Edison Company Governor's Office of State, Planning and Development ATTN: Coordinator, Pennsylvania Clearinghouse P. O. Box 1323 Harrisburg, PA 17120 Mrs. Rhoda D. Carr 1402 Marene Drive Harr isburg, PA 17109 Mr. Richard Roberts The Patriot 812 !!arket Street Harrisburg, PA 17105 Mr. Robert B. Borsum Babcock & Wilcox Huclear Power Generation Division Suite 420, 7735 Old Georgetown Road Bethesda, MD 20014 Ivan W. Smith, Esquire Atomic Safety and Licensing Board U. S. Nuclear Regulatory Commission Washington, DC 20555 Atomic Safety and Licensing Board Panel U. S. Nuclear Regulatory Commission Washington, DC 20555 Atomic Safety and Licensing Appeal Panel U. S. Nuclear Regulatory Commission Washington, DC 20555 1

c-Docketing and Service Section t'

U. S. Nuclear Regulatory Commission Washington, DC 20555 9

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l CROUSE-HINDS SYRACUSE, N. Y.

QUESTIONNAIRE Sn

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CHECKED BY:

INTERVIEWER:

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DATE OF INTERVIEW:

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WO DAY YR LA8EL

$UBJECT IDENTIFICATION CASE NO. i l

(1 51 l

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LAST N AME:

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I FIRST NAME: I f

(36481 M100LE INITIAL:

(4sl (50- M ADDRESS:!

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CITY:

t 7s40 STATE:

l ZIP CODE:

(29 33)

(27 28)

P2RSONAL DATA l

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1. TELEPHONE:

Ansa coon fed)

2. AACE! ETHNIC

1. White,not of Hispanic Origin CODE:

2. Black,not of HispanicCrigin

3. Hispanic

4. American Indian or Alaskan Native

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5. Asian or Pacific Islander

6. Other

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3.$5X:

1. Male

2. Femate (451 (46 51)

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4. What is your data of birth? (month / day / year) h*

CDC/NICSH (C) TF 2.f+6 M

07-79 EXP. 02-80

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RSSPIRATCo.Y THESE HEALTH QU:fSTICNS ARE MAINLY /40UT YOUR CHEST. PLEASE ANSWER YES CR NO, IF POSSIBLE.

'(IF A QUESTICN DCES NOT APPEAR TO SE APPLICABLE, CHECK THE "NOT APPLICABLI" SPACE)

IF YCU ARE IN CCLST AECUT *ahE -ER THE ANS'WER IS YES CR PC, RECCRO NO.

CCLG IA. CO YCU USUALLY HA'E A COLG? (CCt.NT A CCLG '

WITH FIRST SKKE CR C'4 FIRST GOING CUT-CF-CCCRS.

EXCLUCE CLEARING CF THR0AT)........................

1 YES 2

NO (6) h

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IF YES:

S.

00 YCU USUALLY CCUGH AS MUC-1 AS 4 TO 5 TIMES A DAY, 4 CR MCRE CAYS CUT OF THE WEEK?.......

1 _ YES 2

NO (7)

C. CO YCU USUALLY CCCGH AT ALL CN Gci iING CP, CR FIRST THING IN THE MCRNING?........................

I _._, YES 2

NO (8)

D. 00 YCU USUALLY CCCGH AT ALL CURING ?HE REST CF THE CAY CR AT NIGHT ?......................... t.....

1 YES 2

NO (9)

If "YES" to 1A, B, C or D (10.

E. CO YOU USUALLY CCUGH LIXE THIS CN MCST CAYS T-CR 3 CCNSECUTIVE MCNTh5 CR KRE CURING THE Y~AR?......

1 YES 2

l NO 9

!M (11-12) f NO. YRS.

9 NA (12 F.

FCR HCW MANY YEARS HAVE YCU HAD THIS CCUGH?

PHLSGM 2A. CO YCU USUALLY SRING UP FHLEGM.:RCM YCUR CHEST?....

1 YES 2 __,, NO (1'

(Count phleg with the first s:teke or en first, h

going cut-of-decrs.

Exclude phle g from the nose. Count swallcwed phle g)

IF YES:'

~

S. 00 YOU dst.' ALLY 3 RING LP FMLEGM LIXE THIS AS PLO AS TWICE A CAY, 4 CR KRE CAYS CUT CF ThE 'aEEX?.......

1

.YES 2

NO

(' ?

q C.

CO YCU USUALLY 3 RING LP.:MLEGM AT ALL CN GETTING Igu.YES 2

_.1 NO i,-

UP, CR FIRST THING 'N T.-E KENING?.................

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CO YCU USUALLY 3 RING LP.:MLEGM AT ALL CURING THE REST OF ?h5 CAY CR AT NIGHT?..................

YES 2

NO (1-O i

RESPIRATCRY_

i PHL'EGM (CCN'TI (If "YES" :o 2A, 3, C or D - previous page - Ask the following:)

5.

CO YCU 3 RING LP FMLEG4 LIXE THIS CN KST CAYS FCR 3 CCNSECUTI'd KNBS CR MCRE CURING ?HE-YEAR?.........................................

I

,YES 2

NO 9

NA (18)

(19-20) r F.

FCR HCW MANY YE;RS HAW YCU HAD TROLSLE I

NO. YRS.

9 NA (2D WI?H FHLEG4?.................................

EFISODES OF CCUCH AND FHLEGM HAVE YOU HAD PERICOS OR EPISODES OF (in-IA.

creased *) COUGH Afi0 PHLEGM LASTING FOR 3 1

,YES 2

,NO (24)

WEEKS OR MORE EACH YEAR?

• (For persons who usually have cough and/or phlegm) y IF YES:

(25-26)

B.

FOR HCW LCNG MAW YCU HAD AT LEAST

-l NO. YEARS 9

NA (27) 1 SUCM EPISCCE FER YEAR?

%FEEZING 4A.

CCES YCUR CHEST EWR SCLND %HEZZY CR I

YES 2

NO (28)

WHISTLING WHEN YCU HAW A COLD?

B.

CCCASICNALLY AFART FRCM CCLCS?

I

, YES 2

NO (29) 1 YES 2

,NO (30) !

C.

MST CAYS CR NIGHTS?

i l IF YES : TO Q's 4A, 3 cr C - ASK l Y

9 (__! (nap 33 (31-32)

NO. YEARS D.

FCR MCW MANY YEARS HAS MIS SEEN Pc5SENT?

4.

HA%E YOU EWR HAD AN ATTAC< OF kEEEZING THAT 2

NO (34)

T,YES HAS MADE YOU FEEL SHCRT OF SREAm?................

1

+

i (37}'

IF YES :

F.

HCW CLO WERE YCU % HEN YCU HAD YCLR (35-36)

AGE / YRS.

9 NA !

FIRST SUCH ATTACX?

i 9 !,l NA (381 '

1 YES 2

NO G.

MA'E YCU M/O 2 CR.'dCRE SUCi EPISCCES?. -

i 1

9Iq

)

M.

• A'E YCU E'ER RECUIRED MEDICINE CR

'T'D'T FOR 7.-*ECSE) AT ACXCS)?

1 YES 2l NO

!. MA (3?'

_ _ _L

ERE17dt!!!NE55 SA.

IF YCU ARE DISA8 LED FRCN WAC<!NG SY #1Y C210ITICN CTFER THAN MEART CR L'.NG CI5 EASE, sLEASE CESCRIBE #40 PRCCIED TC (see:1cn en Chese Colds 5 Ches. Illnesses, 6A - nex: pass)

NATLHS CF CCNOITICN:

..a S. ARE YCU TRCLSLED SY SHCRTNESS CF EREATH

'.'eHEN HLRRYING CN THE LEEL CA WAC<ING LP A SLIGHT MILL?.........................

tl l YE5 2

No r,, %

T IF YES: ASK C.

CC YCU HAVE TO WAC< SLCWER THAN.:ECFLE CF YCUR AGE CN ZME LEEL SECALSE CF SREATHLE55NE55?......................

If YES 2

NO 9l__,NA

- i, '

O.

00 YCU FER MANE TO STCP FCR SREATH % HEN WAC<!NG AT YCCR C%N tI VIs 2

No 9!

NA

,oACE CN TwE te,Et.?...................

E.

CO YCU E da MANE 70 STOP.:CR SREAm r-F AFTER WALXING ASCUT 100 YARCS (CR 1(i AFTER A.:T.4 MINUTEE) CN Z-E Li'dL?..

YES 2l NO 9i NA p"'T!

F.

ARE YCU TCO SREATHLESS TO LEAVE ThE MCt.,'5E CR 3REATFLE55 CN CRE55ING L(I-'

t-F g

. YE5 2l NC 9I NA CR LNCRE5 5 ING?......................

.Y-l l

t 4

l t

HEST CCLDS AND CHEST ILLNESSES 6A IF YCU GET A CCLo, CCES IT USUALLY Go TO YCUR CHEST? (USL' ALLY MEANS KRE 7."AN 1

YES 2

NO 9

NA (4f l 1/2 ibE TIME.)

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3.

CURING THE PAST 3 YEARS, HAVE YCU HAD ANY C-EST ILLNESSES THAT HAVE XE37 YCU CFF WCRK, INCCCRS AT Ktf, CR IN BED?......

1

,YES 2

NO (46)

Y

~

IF YeS:

C.

OID YCU.2RCCUCE FHLEGM WI m ANY CF WESE C"EST ILLNE5 5ES ?................

1

,YES 2

,NO 9

NA (4~

D.

IN ThE LAST 3 YEARS, HCW MANY SUCi NO. CF ILLNESSES (48-49)

ILLNESSES, WITH CINCREASED) FHLEGM, 010 YCU HANE %HIOf LASTED A WEEX CR NO SUCH ILLNESSES HCRE?...............................

(50) 9 NA PAST ILLNESSES 1.

DIO YCU HAVE ANY LLNG TACCELE SE.CRE TriE AGE OF 16?...............................

1 YES 2

NO (51) 2.

HAVE YCU E'ER HAD AWACTICriS?

1 YES 2 _,NO (21)

I: YES, SPECIFf:

25.

HA'E YCU E'ER HAD ANY C"EST INJURIES?

I, YES 2 _. NO (22)

IF YES, SPECIF.':

f 26.

HAS A ::CC CR E'ER TCLD YOU YCU HAD HEART TRCLSLE?

I YES 2 _,NO (23)

,L I.: YES, ASK:

(24)

26. HA'E YCU HAD TREADENT FOR HEART TRCLSLE IN THE LAST 10 YEARS?

1 YES 2

NO 9

NA 27.

HAS A CCCTCR E'ER TCLD YCU THAT YOU HAD HIGi SLCCD PRESSURE?

I YES 2

. NO (25) 1 I.: YES, ASX:

26),

28. HAVE YCU HAD 2NY TREATPENT.:CR HIGH BLCCD PRESSURE (HYPERTENSICt0 IN THE PAST 10 YEARS?

I YES 2

NO 9

NA e,

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+

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- 4 e

M

l OCCUPATICNAL HISTCRY 1.

IN WHICH FCWCRY AREA 00 YCU CURRENTLY WCRX? :

(27-28)

C CCRE ROCM 01 C

IRCN MOLD 02 C

NCN-FERROUS

~.03 (ALWINW) MOLO C

IRCN GRIND 04 l.

I O

NCN-FERROUS GRINO 05 2.

WHAT SHIFT ARE YOU CURAENTLY WCRKING?

1 2C 3

(29)

r 3.

WHAT IS YOUR CURRENT JOB TITLE?:

CODE:

(30-31)

4. WHAT MONTH AND YEAR DID YOU START CN THIS JCB?

(32-35)

MCNTH YEAR 5.

HAVE YOU HAD #ff OTHER FCWORY JCB AT CROUSE-HINDS?...........................

1 YES 2

NO (36)

(Complete table below in reverse chronological order) 1.

What area did you work in? (Use codes in Q.1 for recording answer) 2.

What was your job?

3.

In what =enth & year did you start on this job?

4.

In what :nonth & year did you seco working on this job?

AREA JOB TITLE DATES OF EMPLOYMENT CCw ENTS l l - l-l l

(43-46),

MO.

Y R.

r

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(47-50) j,,.

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(37-38) l l(39-42) o, l

l l

l-l l

(57-60) f a

uo.

v R.

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l tg i

l l }(51-52)ll l

l(53-56)

' bo,ULl (61-64) y o, f

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l-l l l (12-15) l u o.

- v s.

l (16-19)

(6-7) l (8-11)

, o, y,,

l l

l-l l

(26-29)

M O.

Y R.

I30-33I l l l(20-21) l-l h,(22-25) o, A

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OCCUPATIONAL HISTORY

'6. FAVE YCU HAD ANY.:CAI4 CRY JCBCS) AT 1I YES 2!

no 04) omEa CCepenIES ?.......................

(Cc=P ete the table below i.1 reverse chrenological order) l 1.

~4ha: type of foundry?

2.

~4 hat was your job 7 3.

In what =cnth & year did you start on this job?

4.

In what =onth E year did you stee working on this job?

TENURE

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TYPE CF FCLNORY JCS _ __

FROM/.T.O mm I IHI M o.

Y R.

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v a.

e IiHI M o.

Y R.

I!

HI 1 V o.

Y R.

7.

MAVE YCU EVER HAD A JCS 'nHERE YCU WERE (ICR EACH "YES', SPECIIT Th?. INCCS~RY, EXPOSED TO ANY OF THE FOLLCWING DUSTS?t c3, age 37xx::3c g scepp:3g ex gs)

TENURE EXPCSURE RESPCNSE INDUSTRY JOS Faov/To

&l t i

-o. T (36-39) 1 O rrs --*

g,3jgg II ' i 2 C No (35)

' (40-43)

I'i (43 ia) 1 O rrs~-->

'^-l "C-

2. ASSESTOS l l1 I (49-50) 2 C ho

("4) i vo.

v s.

I (54-57) 1 O YES --*

• C-Y "-

3. SERYLLIUM I l ll I3 (58-61)

' 2 C No (33)

\\t c.

Y A.

1 O r s ---*~

' ' 'T' (53-56)

" 0-Y "-

4. COAL (e2) ii iw (e7-70) o, 2 O so uo vs.

C,..

i ' iW (7-lo) 1 O rzs --*

-M o.-

va.

5. GRAPHITE I I '! '!

(11-4) 2 O so (s) uo v.

! ! Ii ' '

(16-19) 1 O Yrs Me.

v a.

6. SILICA

'..n. '..

6 (20-23)

(other than 2 0 xo (ts)

"m'~'

OCCUPAT!ONAL HISTORY (FCR EACH "YES", SPECIFY THE INDUSTRY, JCB, AND STARTING AND STOP.9ING DATIs)

TENURE EXPOSURE

RESPONSE

INDUSTRY JCB FROM/TO

7. 7,1LC OR 1 O YEs I '. ' v'.. i c2s-283 o

OTHER SILICATES 2 C No

( 24) l' ll l l I (29-32) ao va.

8.

TL.NGSTEN 1 ] YIs I ',,II

! l W4U y

y,,

CARBICE

'! ' i (38-41) 2 O No (33)

M O.

YR.

e OO r

4 4-9 %

TCCACC3 EhcKING 2l NO (42)

, yAsE YCU E'E.R SKKED CIGAR

i.:5?

1 YES (NO MEAN LESS -THA*4 20 PACKS OF (IF NO NO INTERVIEd)

CIGARETTES CR 12 OZ. CF TC8ACCO IN A LIFETIME CR LESS THAN 1

~

CIG;eETTE A CAY FOR 1 YEAR.

..x IF YES:

ASK_

+

2.

00 YCU NCW SKKE CIGARETTES?

1 _, YES 2

NO 9

,__,,, NA (4~

(AS CF 1 KIJTH AGO) 3.

HCd OLD WERE YCU kHEN YCU FIRST AGE / YRS.

(44-45) 9 _,MA (45 STARTED REGUt.AR CIGARETTE SMCXING?

4.

IF YOU HANE STCPPED SMCKING CIGARETTES CCMPLETELY, MCW CLD WERE YCU 'oHEN YOU (47; (4s-49) 1 STILL SMCKES AGE /STCPPED STCPPE0?

I ASK - PRESENT SMOKER ONI.Y 5.

HCd MANY CIGARETTES PER CAY CO YCU (50-51)

(52)

CIG./ CAY 9 _ NA SMCKE NCd?

i t

6.

CN THE ANERAGE.CF THE ENTIRE TIME (53-54) l YCU SMCKED, HCd MANY CIGARETTES DIO CIG./ DAY 9

NA (55' L YCU SMCKE PER DAY?

.7.

00 CR 010 YCU INHALE THE CIGARETTE SKKE?

1 NOT AT ALL

~~

2 SLIGiTLY (56)

J _ MCCERATELY 4_

CEEPLY 9

. NOT /#PLICABLE 11 (79-90) e w

HHE 78-4 Enclosure. 2

- Department of Health, Education and.Welfars Public Health Service Center for Disease Control National Institute for Occupatienal Safety and Health CUESTIONNAIRE l

l l

ASSURANCE OF CONFIDENT 1AllW: The United-States Public Health Servicz hereoy grves its 2.ssurar.ca tnat your icantity anc your relatiensnic to any infcrmation i

obtained by reasco of your partic. cation in t: a Sh*l l Study will be kaot l

confidential in accorcanca with PHS Requistions (42 C.eR 1.1011.1C8) and will not otherwise be disc!csed.

\\

~

i 1

?

CDC/flIOSH (C)'TF 2.20A

~

01-78 EXP. 07-78 S

__.,_..._._,_.y y-...

..y

.,,,,m-p,..,,

HHE 78-4 q

+

INTERVIEW"ER:

I (40-41)

~

l l

(42-47)

OATE OF INTERVIEW:

MC DAY VM l

uaEL SUBJECT IDENTIFICATION l

(I"5)

CASE NO.

l l

l l

l (7-25)

LAST NAME:

l l

l l

l (26-38)

FIRST NAME:

/

/0/// (76-80)

MICOLE INITIAL:

_ -(39)

First 31 rs ast name

! -l l

l l

l l

l l

l f

ADDR ESS:

l l

l l

l l

l l

l l

-l l

(6-26)

CITY:

!l l

l (29-33)

(27-28)

ZIP CODE:

STATE:

P!RSONAL DATA

~

~

~

~

1. TELEPHONE:

AREA COCE

2. RACE / ETHNIC

1. White.not'of HispanicCrigin CODE:

2. Slack, not of Hispanic Crigin

3. Hispanic

4. American Indian or Alaskan Native

5. Asian or Pacific Islander

3. SEX:

1. Male

2. Female l

l-(46-51)

4. What is your date of birth? (month / day / year)

~

5, Whrt is the last grade of school you c=mpfeted?

ELEMENTARY = 01 -08 SECCNDARY = 09 - 12 COLLEGE = 13 (1 year) 14 (2 years) 15 (3 years) 16 (4 years) 17 15 years) 18 (6 years) 19 (7 or more yearsi

6. Under federallaw people participating in our surveys CO NOT have to tell us their social security nu useful and helps us do followsp studies. May I have your social security numberi (54)

REFUSAL: 2 (55-6[.

l l

l l

l SOCIAL SECURITY NUM8ER:

First 3 ltrs last nme /_f_/_ /n/2/ (76

-t-gCg!OSH (C) TF 2.29 A EXP. 07-78 e

OCCUPATIONAL HISTORY Now I'm going 13 rsk you about th~) jobs you've held, since you started working rege! rly. I'd liks t3 begin with you'r present job, here at Shell Chemical Co.

and go back to your first job.

1. What department do/did you work in?

?-

2. What is/was your occupation or job title?

3. What exactly is/was, your main job or activity? (What kind of work do/did you do most of the time?)

4.

In what month and year did.you start on this job?

[ -

y.

5. And in what month and year did you stop working on this job?'(DO NOT ASK FOR CURRENT JOB.)

6. Have you held any other jobs at Shell Chemical Co.

7 (ASK O's 15 FOR EACH JOB. RECORD INFORMATION BELOW. ASK Q. 6 UNTIL UNPRODUCTIVE.)

C DEPARTMENT JOB TITLE DATES OF EMPLOYMENT WORK DESCRIPTION 1 I H I

I =>=

i n

1 (2629)

MO.

vR.

l I

I l

lmau-l i HI l**

ao n

.o o.

l l

l' l-I I l 4o.4m i

i M o.

v R-r Ili i

i HI i

c is.o.

m o.

v a.

_U ll I H I J,_,,,

I 3

I 40.

Y R.

l

' f as491 (so-533 o.

v n.

P l I H

I I<-">

l s

i i

s i i.,2-,.,

I. l 2 2,

I I I I I,

.n

.o.

1 I

l-l I lns.sn wo.

Y a-I l \\

-1 1 1,os.is)

]

i, !..,,

j tl l

li.....

-o.

v a-i__

fl (2s 296

?

wo.

v n.

3 j

l(22 25) I I H I

l.,o o,,-

~

I

_ t2 21)

Mo.

v s.

2

~

[

OCCUPATIONAL HISTORY - PREVIOUS EMPLOYMENT

1. What is the name cf the company?

2. What kind of company (was) is it; what do they (did) do there?

(s)

3. In what year did he start working there?

4. And,in what year did he stop working there?

5. What was his pation or job title?

6. What exactly was his main job or activity?

(What *4nd of wiark did he do most of the time?)

7. Did he work in any area where he was exposed to dust, fumes, gases, chemicals, or other substances?

IF YES:

8. bat was he exposed to?,

9.

Can you think of ar.y other jobs?

(R EPEAT O's 2-8 FCR EACH 43. REPEAT O. 9 UNTIL YOU ASCERTAIN THAT YCU HAVE RECORDED ALL OF THE HUSBAND'S JOBS.)

NAME OF TYPE TENURE WORK EMPLOYER COMPANY FROM/TO

.10R TIT 1 F OF9CP!oTfnN FYpnSt JR cR l

e uo.

v a.

'CO L1J 1

l vn.

l uo.

1 (n i as-ts) ggg

;i gg i

WORK NAME OF TYPE TENURE EMPLOYER COMPANY FROM/TO JO3 TITLE DESCRIPTION EXPOSURES I

I j

l

}l ll Ii l

1 MO.

Y M.

ll ll l J:

l va. l uo.

I (22) '

<2soci,

I i i LJ_! I I h l

isi.sai !

NAME OF TYPE TENURE WORK F3;n ovFo r nMp ei.s'v canavTn

. inn Tive F nperpipTinN Fypnstinct i

t I

i li l I R!

_j i

l

. uo.

Y n.

I Cl l ll M O.

Y R.

(3U (M4) eas su '.

NAME OF TYPE TENURE WORK EMPLOYER COMPANY FROMITO JOB TITLE DESCRIPTION EXPOSURES 3 MG YA 3

LLJ l I l-l MO.

Y A.

i l

il 4.-

(S2) l 853 401 gi 461 66)

First 3 Itrs last name /_fj._/ 0/6/ (76-80) 4 I

OCCUPATIONAL HISTORY (Con't)

MO.

YR.

FROM: /__f_f-/_/_f 7-1c 7.

Have you ever worked in the vicinity of a DBCP druming operation?

1/_/YES 2/_/NO 8/_/0K TO:

/_f_/-/_/_f11-1 (6)

FROM: /_f J -/_]_ f16-19 8.

Have you ever worked in the vicinity of DBCP production? 1/_fYES 2/_/NO, 8/_/0K TO:

/_f_f-/_f_/20-22 (15)

~

9.

Have you ever been exposed to a DBCP spill?

1/_fYES 2/__/NO 8/_/0K TO:

/j_/-/_/_/29 h1 (24)

FROM: /_/_/-/_/_/34 10. Did any of the OBCP chemical get on your skin?

1/_fYES 2/ /NO 8/ /0K TO:

/_f_f-/_/_/38 21

(.12) -

11. Do you have any health problems that you feel are related to substances or physical agents present in your work environment?

1/ j YES 2/_fNO 8/_/DK (42)

-~ "

COPJ4ENTS:

s CODE: /

/' ~/

(43-44)

First 3 ltrs last name /_f_f_/ 0 / 7/ (76-80) 3

DATES OF EMPLOY.'.1ENT "In wha: rnontn and year o.o you start working with this?

l.

"Ana sr. er.at rr.oatra.:.o ).4r. c.s ou stop working with this?

r DATES OF DATES OF SUBSTANCE

RESPONSE

EMPLOYMENT SUBSTANCE RESPONSE EMPLOYMENT 7-10

j

YES 1

i YES i

1.

Weed killers

~

j T

0 2-U nO 21

'N yo, y o, l-8i

1. DK 8I

!DK i

i M O.

v a.

MO.

R-

-(6) j j _j o

.g i*cn 1 I i YES 16-19 1

YES

' 7$"

2. Pesticides 2I INO~

i 2I IN ~

u o.

v a.

o.

v a.

DK 8 I IDK i

8I 3

M G.

v a.

MO.

(15) 20-23 ni YESl Os to 1 I iYES 25-28 1

t e

d

!a j

I

3. Chemicals 2i NO --

2I IN

'i uo.,

v a.

o.

v a.

8i

'DK 8I iDK j

i (24)

'" 29-32.

' ** 3 3 1 i

! YEs 34-37 1

YESi s.

_b I

4. Degreasers 2

NO 2;

'N l'

\\"-

Y "-

or other solvents 8i DK 8I iDK j

1 MO.

Y a.

M ~

VR' (33) 38-41 (24 1 I iYES 43-46 k YES' 8 3' #'

5. Ionizing 2

tNO~

2!

IN Radiation "a

Y "-

Y"-

sI iDK 8i iDK X,a.

(42) wo-vn essi uo.

47-60.

,, m;,

First 3 ltrs last nane

/_ f _/_/ O/ 8/ (76-80)

?

l O

e 6

,e w wy~

MEDICATIONS flow I'm going to read a list of medications.

In the last three months, have you taken any of the following medicines?

i 1.

Oral contrapceptives, 1 O YES_

Name:

y

. birth control pills,

( -10) pills to regulate 2'O NO periods, or medicines l for hot flashes 8 O OK (11-14)

(6) 1 1 O YES_

Name:

i 2.

Estrogens, female

(!

{16~19}

hormones 2 O NO ji l

l (15).

(18~'3) 1 OYES]Name:

l l_

3.

Steroids, corti-l steroids (25-28) 2 O NO l-i 8 O OK (24)

(29-32) 1 O YES game.

.j

_j l

j 4.

Androgens, male hormones, testosterone j

2 O NO (34-37) 1

-l l

K (33)

(38-41 )

1 O YESJ 5.

Thyroid pills Name:

l l_;

j 2 O NO

'(43-4@

J-l I

i 8 O OK (42)

(47-50) i 1 O YE5_ !

8 q

[

Name:

6.

Insulin 2 O NO (52-55) i l

l-l i

l 8 O DK (51)

(56-59)

S G

e 7

EDICATIONS Now I'm going to read a list of medications.

have you taken any of the following medicines? In the last three months, 1 O YES l 7.

Pills for diabetes

'Name:

j 2 O NO (61-64)

I I

8 O DK

/ / / / 0 / 9 /(76-80)

(60) 465-s,1 1 O YES_

8.

Diet pills prescribed Name:

for weight control 2 O NO (7~'*) '

i l

8 O OK (ii.sg) 1 O YES Name:

J l

9.

Diuretics or water l

pills 2 O NO I## ~"

'l l

8 O DK (zo.;3) 10.

Pills for gout 1 O YES_.Name:

j j

l_

j j

2 O NO

~#}

i l

l 8 O OK

(.t9.J a) 11.

Medicines for high 1 O YES Name:

I t_i i

cholesterol or high triglycerides 2 O NO (3V-37) r l

l-l l

!l 8 O OK r-

,,, y (ss) 8l 12.

High blood pressure Name:

l l-l pills cus.y;>

HI l

i 8 O OK (yg,y

_ igr.so) l-i

j. l (JJ.Sv) i

~

t 8

-,,y-p

--v

---,.w, w,e..

._3,..

DEDICATIONS N'ow I'm going to read a list of medications.

In the last three months,

'have you taken any of the following medicines?

' cy.s,)l - l !

13.

Anticoagulants or 11 IYES,_ Name:

blood thinners 2I INO l

l-l 81 1 DK

.g,gy (55) mit 14.

Phenothiazine medi-l1l lYES.- Name:

cines, like thorazine I

l trilafon, s telazine, 21 INO

("##

prolixin or mellaril

,8I IDK

_l

/ / / /'l / 0 / (76-80)

(66 M2)

G 9-2) l!

l i

15.

Heart regulating 1.l I YES - Name:

7 N

I medicines.

Things (f.n/

for irregular heart 2I INO

, ~i i

beats, like nitro-i l _J l l

1 I

glycerine or digi-81 lDK (a./y) talis.

m3 l

iI (l$-/2) l

.~-

(4}

11 l YES - Name:

-l l

l 16.

Have you taken any t

other medication in

-M8 43y the last three (3) 2I INO months?

l il l

81 IDK ni, ca v-n)

Ufl

.l j

l l

in s0 l

]

f##~3##

/_ /_/_/ 1 / 1 / (76-80)

-l IH!

hs -35)

Hi Go-va )

9

WEIG)T HISTORY 1.

Has your weight changed in the past two weeks?

N0..................

1 GAINED..............

2 i

L0ST................

3 (DON'T KNOW)........

8 (f,)

IF GAINED OR LOST ASK:

2.

What was the net change.in pounds ?............................

LBS. (7-4) 3.

How many pounds did you weigh when' you were 187..................

LBS. (/o -/J.)

4.

What is the most you have ever weighed LBS. (/J-/5)

(excl udi n g p regn a n ci e s ) ?..........................................

HEALTH HISTORY I'm now going to read a list of health conditions. Have you ever been told by a doctor that you had any of the following conditions. Please answer YES or N0 to each one.

(READ EACH CONDITION AND RECORD A RESPONSE.

IF YES, ASK THE SECONDARY QUESTION)

IF YES ASK:-

DATE: In what year were you first told about this conditon?

CONDITION

RESPONSE

DATE

1. Kidney or 1 O YES 19 l l

l What kind of a kidney condition?

bladder 2 O NO condition 8 O DK SPECIFY:

(17-/8)

CODE: l l

l(,9.:.) l l j(gj.22)

(a)

2. Heart 1 O YES 19l Attack

^

3 O.MULT.

8 G DK (av.as)

( 2.3) 3.' Angina or 1 O YES

_19 l l

l angina

~

2 O NO

pectoris a O OK (26)

(27

• SI )

~

10

SECONDARY CUESVI@@

IF YES ASK,_

DATE in what y:ar w:r2 you first told about this condition?

CONDITION R E SP_ONSE DATE 4 Aav other 1 O YES 19 l l

l What kind Of Cardiovascular disease?

card,,iovascular disease s O oK SPECIFY:

(29)

(s o -as)

CODF: l l l (Jr-J3)

5. HIGH 1 O YES 19 cholesterol

^

2 O NO 8 O OK (3Y)

(35-3G)

6. High 1 O YES 19l l

triglycerides 8 O OK (37)

(Jf-J1)

Liver 1 O YES 19 l l 5

1 O Hepatitis 3 O Cirrhosis 7*2 condition 2 O NO 2 O Enlarged liver 4 O Other sc city or jaundice a O ox 7,

~

(vs)

(Y8)

(V/- %1 )

IF YES ASK:

TR E ATME NT:, Did you receive medical or surgical treatment (for this condition?)

,,g IF YES ASK:

.I DATE:

In what year were you first treated (for this condition?)

~

TOLO?

TREATED?

TREATMENT CONDITION

RESPONSE

RESPONSE DATE 1 O YES 1 O YES 19 l l

g, p,9 2 O NO 2 O NO blood pressure a O DK 8 O oK i

(44).

'(4$)

(VL*47)

O 11

f IF YES ASK:

TR E ATME NT: oid you r:ceive medicIl or surgical treatmInt (for this c:nditi:n?)

IF YES ASK:

DATE:

In what year were you first treated (for this condition?)

,T,OLDP TREATEOF TR E AT,M ENT CONolTION

RESPONSE

RESPONSE DATE IF YES: What type of cancer?

(54~83) 1 O YES 1 O YES 19 l l

9. Cancer 2 O nO 2 O NO SPECIFY SITE:

CODE: / / /

8 O oK 8 O oK Were you treated with:

(54-54)

Chemotherapy?

1 /_f Surgery 3 /_f (yt)

(49)

(so-4d Radiotherapy?

2 /_/ (Can be all three) 1 O YES 1 O YES 19l l

l

10. Asthma 2 O NO 2 O NO 8 O OK 8 O oK (57)

(ss)

( 59-se) 1 O YES 1 O YES 19l l

l

11. Stroke 2 O NO 2 O NO 8 O OK 8 0 oK (si) e c.1)

(43~GV)

, QUES.12-14 ARE FOR MALE RESPONDENTS ONLY l

l 1 O YES 1 O YES

[9 IF YES ASK: Did the mumps involve your

12. Mumps testicles?

2 O NO 2 O NO 8 O OK 8 O og i O YES 2 O NO 8 O,oK (t.1)

(45)

(4c)

( c 7-4 f)

/ / / / 1 / 2 / (76-80) l J9!

f 13.

1 O YES 1 O YES l-P ro.s ta te 2 O NO 2 O NO Inrection 8 O oK 8 O oK

((,)

(i)

(t 9) 1 O YES 1 O.YES 19l l h

14. Epididy-mitis 2 O NO 2 O NO (testicular 8 O oK 8 O OK pain &

swell ing)

(to)

(4)

(s:,-s3) iz l

i

!\\

IF YES ASK:_

j;

'TR E ATME NT: old you receiro rnedical or surcical treatmtnt (for this c nditiin?)

i IF YES ASK:

oATE:

In what year were you first treateel (for this condition?)

i;

.)

Tot D?

TREATEDF' TREATMENT e

CONDITION

RESPONSE

RESPONSE oATE 15 Thyr:id 1 O YES 1 O YES 19 l l

~

f-condition l.

2 O NO 2 O NO 8 O oK 8 O oK DY)

(!$)

(15 *l7 )

16 Gall bladder 1 O YES 1 O YES 19 ! l l

+

cindition 2 O NO 2 O NO 8 O oK 8 O oK (as]

(s1)

(20-21) 17 orab:res 1 O YES 1 O YES 19l ! l 2 O NO 2 O NO 8 0 oK 8 O DK

[

i.

c.tz) cas) ca v-as')

1 16 Anemia 1 O YES 1 O YES 19l

?

n

~

~

2 O NO 2 O NO i

8 O oK 8 O oK I

(.ts)

(27)

(21-af) l I

19 Ulcers 1 O YES 1 O YES-+

19 2 O NO-2 O NO 8 O oK 8 O OK t

i (a*)

(so)

(aa-33)

'20 Arthritis or 1 O YES 1 O.YES 19l l i t

theumatism 2 O NO 2 O NO i

i 4

8 C oK 8 O oK cy)

(at)

(as -37 }-

l u

---

m

---m.a_

ewe %Mme. a

• • M

CONDITION

RESPONSE

DATE' 21.

Fhve you' 1 O YES 19 Which side:

ever had 2 9 no a hernia 1/__/RIGHT 2/_/LEFT (VI) o p e ra ti o n,:

a O DK (sg)

(37-ve)

27. In the last five years, were you hospitalized for any other illness or injury?.........

1 O YES 2 O NO (V0.)

Y IF YES ASK:

CONDITION Wh/ were you hospitalized?

DATE in what year were you hospitalized?

CONDITION DATE CONDITION DATE CONDITION DATE 23.

25, 27, 19l l l 19 19

+

+

+

("*-s*)

(sa-sv]

cye.va)

II III III

('v.5 44)

(y7-vs)

(si sa) 26 28 24.

19l l

l 19l l

l 19l l l

+

+

+

ggs.sgy c ei-s.1)

L c.s-u )

III III II (SS-SC)

(59-60)

( 43 - G V)

First 3 ltrs last name / / / /1/3/

(76-80)

+

til

F AMILY, HISTO RY 1,.

I s y ou r f a th e r a tiv e r......................................... 1 O YES 2 O NO 8 O ox ((,)

2.

Is y ou r mo th e r aliv e?........................................ 1 O YES 2

NO 8

DK (7).

3.

How old is your father? or (How old was your father when l l AGE (f-9 )

he d ied ? )..........................

4.

How old is your mother? or (How old was your mother when sh e died ? ).........................

AGE (10 -//)

5.

What is the total number of children you have had, not including y

g g step children, foster children, or children by adoption?................ I

.I I CHILDREN

[t.2, - /J )

~

What is the total number of brothers, sisters, half-brothers, and 7.

half-sisters you have had?..................................... l: l l

BROTHERS / SISTERS (tV-/5)

IF SUBJECT HAS BROTHERS OR SISTERS ASK:

8. Of these, how many are living?........................*....

l BRO / SIS LIVING [11.-/7)

Has (Did) your father had (have) any of the following disorders?

1.

Heart attack or angina?...................................... 1 YES 2

NO 8 0 oK (ig) l Y

IF YES ASK:

2. Did this oc:ur before he was 60?.......................... 1 YES 2 O NO 8

OK (19) 3.

Hign blood pressure.or hypertension?............................ 1 YES 2

NO 8 O 'oK (ae) 4 High cholesterol, high triglycerides or high blood fats?.....

1 O YES 2 O NO 8

DK(.21)

W

FAMILY HISTORY (Continued) 5.

Strokes, apoplexy, cerebral vascular disease?....................... 1 YES 2

NO 8 O ox (at) 1 O YES 2 O NO 8 O ox (43)

E.

c i a b e te s ?................................................

Has (didl your rnother had (have) any of the following disorders?

1 YES 2 O NO 8

DK (JY) 7.

Heart attack or an gina ?.....................,................

IF YES ASK; p*c -

8. Did this occur before she was 607.......................... 1 O YES 2 O NO 8 O ox 9.

High blood pressure or hypertension?........................... 1 O YES 2 O NO 8 O ox (J6)

10. Strokes, apoolexy, cerebral vascular disease?....................... 1 O YES 2 O NO 8 O ox (.27)

11. High chef estarol, high trigtyeerides, or high blood f ats?............... 1 O YES 2 O NO 8 0 ox(M) t O YES 2 O NO 8 O ox (49)

12. D ia be te s ?................................................

(IF SUBJECT HAS NO CHILDREN: GO TO O.18).

How trany of your children whether living or not, have had the following disorders?

~

13. Hear ^ attack or angina before age 60?...........................

l l

l

14. High blood pressure or hypertension?...........................

Strokes. apohexy, cerebral vascular cisease?.......................

15.

~

16. High cholesterol, high triglycerides, or high blood fats?...............

~

17. D i a be t e s ?................................................

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FAMILY tilSTORY (Continued)

GO TO Q. 23.

IlF SUBJECT HAS NO BROTHERS. HALF-8ROTH'ERS. SISTERS, OR HALF-SISTERS:

How many of your brothers and sisters, or half brothers and half-sisters, whether living or not have had the folltwing disorders?

( 40 - VI)

18. Heart attack or angina before 60?..............................

19. High blood pressure or hypertension?...........................

~

20. Strokes, apoplexy, cerebral vascular disease?.......................

~

21. High cholesterol, high triglycerides, or high blood' fats?................

~

22. D iab e t e s?.............................................

For some health problems it is imoortant to know whether the father and mothere were related to each READ:

~ other before they married. For this reason, we are asking the next two questions.

23. Are your parents (not step. foster or adoptive) 1 O YES 2

NO 8 O DK (f*)

first or second cousins to each other?...........................

1 O YES 2 O NO 8 O DK (5s)

24. Are you a first or second cousin to your present spouse?............

FirSt 3 itrS laSt nar.e

/_ f _/ _/ 1 / a / (76-80) 1,,

i o

l l

t 17

In'this part cf the intervi w, I'll be asking you about your sociil habits.

SMOKING HISTORY o

1 O YES 2

NO (6) 1.

Do you now smoke cig ar ettes?.......................................

IF NO:

2. Have you ever smoked cigarettes?................................ 1 O YES 2 O NO 7

IF NO TO O.1 AND Q. 2: GO TO ALCOHOL CONSUMPTION Y

ASK EX. SMOKERS:

l _

AGE (8-9)

3. How old were you when you gave up smoking cigarettes?...............

l AGE (IC-Il) 4.

How cid were you when you started smoking cigarettes regularly?.............

5.

On the average, how many cigarettes do/did you smoke a day?...............

CIG/ DAY (12-13) 6.

Co/did you inhale the cigarette smoke?................................. t O YES 2 O NO (14)

ALCOHOL CONSUMPTION REAO: Since lipid levels may be affected by the consumption of alcoholic beverages, everyone is being asked the fo!!owing question or questions r ncerning alcohol consumption.

a 1.

During the past year, have yoe, had at least one drink of beer, 1 O YES 2 O NO (15) wi n e, or IIq u o r ?..................................................

(IF NO: END INTE,RVIE'.*ll 2.

About how often do you drink some kind of alcoholic Severage?

O1 (16)

D aily or almost every day?.....................................

Thre e or four times a week?...................................

O2 (17)

O nc e o r twic e a w ee k?.......................................

O3 (18)

O nce or twice a month ?............................

O4 (19) t less o f ten than once a month?.................................

Os (20)

( DlO N'T KN OW ).............................................

Os (21) 1 It 1

ALCOHOL CONSUMPTION (Continued) 3.

When you drink beer, about how many bottles or cans of beer i i do y ou d rin k ?................................................. I I

BEER (22-23) 4 When you drink wine, about how many glasses of wine do you j

WINE (24-25) drink?.............................,..........................

^

5.

When you drink highballs, cocktails, or mixed drinks, about how COCKTAILS (26-27) many do you drink?.............................................

6.

When you drink liqueurs or other alcoholic drinks, about how LIQUEURS (28-29) ma ny G y ou d rin k?.............................................

During this past week about how many bottles or cans of 7.

b eer did y ou d rink ?.............................................. l BEER (30-31) 8.

During ~.his past week, abcut how many glasses of wine did yout'. ink?....................................................

WINE (32-33) 9.

During this past week, about how many highballs. cocktails g

g j f

I COCKTAILS (3d-35) or mix ed drinks did y ou have?...................................... I During this past week, about how many drinks of liqueurs or 10.

other alcoholic beverages did you drink?............................'... ! ! !

LIQUEURS (36-37)

First 3 ltrs last name /_/_/_/ 1 / 5 /

(76-80) e 1*

1 l

6 l

~

4 19 l

l

-.. -, - ~ -,. -.. -, --

FOR FEMALE RESPONDENTS ONLY MENSTRUAL HISTORY _

r, N:;w I'm going to ask you a few questions about your menstrual periods.

e AGE (s.7) 1.

How old were you when you had your,first period?....'..~.............

1 O YES 2 O NO

(.[.)

2. Are you still having periods at all?...............................

(s)

'~

if IF NO:

L

-:g.

AGE (s-10)

3. At what age did you have your last period?.........................

I I1

4. Did your periods: sto p natu rally?.................................

I i2 stop due to surgery............

I 13 stop due to radiation?...........................

stop due to other reason?.........................

,i 14 I

I5 t

stop for some unknown reason?...

(11)

Y m,

IF "OTHER REASON": Specify IF YES:

i

5. About how many days are there from the first day of one period DAYS (12-13)

I to the first day of your next period?.......................

i.

6. About how many days does your period last, that is until the OAYS (18-15) j bleeding completely stops?..............................

P,, s-a. ;.

i ASK Al.f. RESPONDENTS

. 7. Since leaving high school, have you noticed any of the following changes in y:ur menstrual cycle? irregular pen. ds?............................... 1 :

LYES 2 :,

INO (tal o

. e,i-2 Skipping periods?.......................s....... 1 I LYES 2l I NO (17) increased flow ?.............................. 1 I I YES 2 I I NO (ts)

Decreased flow?................................. ' T I IYES 21 i NO ffs) l e

I Increased pain or cramping?....................... 1I IYES 21 i NO (20) i I

Some other change?.............................. I l I YES 21 I N O (2tl l

i Y

y i

IF "OTHER CHANGE" : Specify 1 s NOCHANGE..................................

Il IYES 21 NO (22) j i l w~,

E e

-4 P

,e c1 9D

.=M l

,egx.

FOR FENALE RESP 0?lDENIS UNLY

~

MENSTRUAL HISTORY (Cont'd) 4 IF ANY REPORTED CHANGE

8. In what year did you first notice this change?..................... 19 (23-241

9. About how long did you have this?..............................

MONTHS (2s.27) e 10 When you first noticed this, weie you taking birth control pillsf 1

YES 2 M NO (2s) l IF YES. 11. About how many months had you been taking the pill?..

MONTHS i

S (29-31)

IF NOT TAKING THE PILL:

12. Did you have an IUD when you first noticed this change?............... 1 YES 2 C N O (32)

I Y

l IF YES: 13. About how many rnenths had you had your IUO7......

I MONTHS (33 35)

First 3 ltrs last name / // / F/O/ (76-80) 90 e

,=

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8 h

. al e

p g+

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• T~"t*'

T O N N ~

• f"W '* 9-

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I F0R FEMALE RESPONDENTS ONLY Now I will ask you some questions about some possible physical changes unich people may occasionally have.

1.

Have you noticed any increase in your facial hair 1 /__/ YES 2 /_fNO 8 /_/ D K (36)

IF YES:

2.

Date first noticed

/_/_/-/_/__/ (37 ve) i Month Year 3.

Have you noticed any incre as e in your body hair?

1 /_f YES 2 /_/NO 8 /_fDK (V/)

IF YES:

4.

Date first noticed

/__/__/-/_/_/ (va-45)

Month Year 5.

Have you noticed any change in your breast size?

I / _/ YES 2 /_/NO 8 /_/DK (Yd)

IF YES:

6.

What type of change 1 / _/ Increase?

2 /_/ Decreased? (47) 7.

Date first noticed

/_/_/-/_/_/ (vs.st)

Month Year 8.

Have you noticed any change in your muscle size?

1 /_/ YES 2 / _/NO 8 / _/DK (54)

IF YES:

9.

Describe:

l c a s..-

/

/ (53-S')

l Now I am going to ask you a question of a general nature.

l 10.

Have you ever traveled in the tropics?

1/ _/YES 2/ _/NO 8/ _/DK (55) l IF YES:

I l

11.

Where?

CODE: / / / (56-57) t l

l 12.

When?

/ _/_/-/ _/_/

(58-61)

Month Year i

First 3 ltrs last name / / / / 1 /S/ (76-80) fylt

eFOR MALE RESP 0llDENTS ONLY Now I will ask you some questions about some possible physical changes which people may occasionally have.

1.

Have you noticed any decrease in your facial hair, in your beard?

1/ _/YES 2/ _/NO 8/ _/DK (6)

IF YES:

2.

Date fi rst r.oticed:

/ _/ _/-/ _/ _/ (7./o)

Mo.

Yr.

3.

Have you noticed any decrease in your body hair?

1/ _/YES 2/ _/NO 8/_/DK (ii)

IF YES:

4.

Date first noticed:

/_/_/ -/_/_/ (12-/t)

Mo.

Yr.

5.

Have you noticed any change in your breast size?

1/ _/YES 2/ _/NO 8/_/DK (16)

IF YES:

6.

Date first noticed:

/_/_/ -/_/_/ (s7.ao)

Mo.

Yr.

7.

Type of change 1/ _/ Increase 2/_/ Decrease (as)

I l

8.

Have you noticed any loss j,.

in your muscle size?

1/_/YES 2/_/NO 8/ _/DK (22-)

IF YES:

SPECIFY CODE: / / / (23-2a)' "

Now I am going to ask you a question of a general nature.

9.

Have you ever traveled (8f) in the tropics?

1/_/YES 2/

/NO 8/

/DK IF YES:

l 10.

Where?

CODE: / / / (26-27) 11.

When?

/ _/_/-/_/_/ (JP-J /)

Mo.

,Y r.

First 3 ltrs last name

/j / /1/ 7 /

l 93 i~

ASK FOR ALL MARRIAGES:

a r age Date:

/ _/ _/-/_/ _/(c.9-II.

PREVIOUS SPOUSE Ho.

Yr.

1.

Have you had trouble having a family?

1/_fYES 2/_/NO 2/_/DK [/3) 2.

How many children were born alive in this marriage?

/_/_jNo. of children (/v-/4) 3.

What are the birth dates'of your 4.youncest chiTdren born during this marriage?

1/_]_/-/_f _f 2/_j_j-/_f_)

3/_f_/-/_l_/

4/ J _j-/_f_]

Mo.

Yr.

Mo.

Yr.

Mo.

Y r.

Mo.

Yr.

(16-11 )

(ao-23)

(av-27)

(al-3 )

4.

How many miscarriages or spontaneous abortions occurred?

/_j_/No. (s: 33)

's.

Date(s):

1/_/_/-/_/_/

2/_/_j-/_/_/

3/_/_/-/ / /

Yr.

No.

Yr.

Mo.

Y r.

No.

(sy 31) i 3 3-V')

Cv2-95)

6. Mcw many stillbirths occurred?

/_f_/No. of stillbirths (ys.yr) 7.

Date(s):

1/_/_J-/_j_/

2/_l_j-/_/_)

3/_/_/-/_]_)

Mo.

Y r.

No.

Yr.

No.

Yr.

(n-ss)

(sa-SC)

(ss ss) 8.

How many ch:1dren, born alive, were born with a defect?

/_f_/No. of children (sena) 9.-

Specify type of birth defect or malformation and the date of birth: j f

p f gj Type:

Type:

Birth date: /_/_/-/_/_) (4-1)

Birth date:

/_/_/-/_/_/(tvn)

Mo.

Y r.

No.

Yr.

CODE:

/_f_)

/_]_J (10-13)

CODE:

/_f_)

/_l_) (1121) 10 What is the birth date of your spouse?

/_/_/-/_/_/ (22.ar)

No. -

Y r.

11.

Do you or your spouse use anything to prevent p regnancy?................. 1/_fYES 2/_fNO 8/ /0K (24 ) -

IF YES:

12.

What were or are you using?

1/_/ PILL 2/_jIUD 3/_jDIAPHRAGM (47) 4/_fHYSTERECTOMY 5/_ / TUBES TIED 6/,_/0THER:

Specify CODE: / / /

First. 3 ltrs last name / / / ' /.2 / / / (76-80)

(28-29)

__s_m_

y;*

_ es

• rw--*

7_ 7 - *

• * * =, _

• _ _ _ _- - - - ~

• f

+.-

p

• 7

"'**-e***__e*

• + -

7 l

dK FOR ALL MARRIAGES

((,. 9 )

III.

PREVIOUS SPOUSE Marriage Date: /

/

/-/

/

/

MO.

Y va.

1.

Have you had trouble having a family?

1/_/YES 2/_/NO 8/_/0K (/3) 2.

New many children were born alive in this marriage?

/_f_/No. of children (/NS) w' hat are the birth dates of~ your 4 vcur,9est chiltiren born during this marriace?

3.

1/__f_f-/._]_/

2/_/_/-/_l_/

3/_/_f-/_/_/

4/_/_/-/__f_f Mo.

Yr.

Mo.

Yr.

Mo.

Yr.

Mo.

Yr.

(ss-sf)

( e.23)

(21 21)

(:13o) 4.

Hcw many miscarriages or spentaneous abortiens cccurred?

/ /_/No. (32 33) 5.

Date(s):

1/_/_/-/_/_/

2/ / /-/_/_/

3/_ f _/-/ / /

Mo.

Yr.

Mo.

Yr.

No.

Yr.

(3131)

(31 vs]

(42.vt)

6. Hcw many stillbirths-occurred?

/_/_/No. of stillbirths (vs.vi) 7.

Date(s):

1/_/_/-/_/ /

2/

/__f-/ / /

3/_/__/-/_/_/

Mo.

Y r.

Mo.

Yr.

Mo.

Yr.

(vs.ss)

(s2.st)

(S4-59) 8.

Hcw many children, born alive, were born with a defect?

/_f__/No. of children

( o.41) 9.

Specify type of birth defect or malformation and the date of birth: 7 f f fgg Type:

Type:

Birth date: /_/_/-/ / / (?.9)

Birth date:

/_/_/-/_/_/ (sv.st)

Mo.

Y r.

Mo.

Yr.

CODE:

/_f__]

/_/_) (se.13)

CODE:

/_/__/

/_/__f.cig.;t) 10.

What is the birth date of your spouse?

/ _ /_ J-/ / / (:;.25)

Mo.

Y r.

11.

Do you or your spouse use anything to p c <ent p re gnancy?................. 1/_/YES 2/_/NO 8/_/DK (J'.1 IF YES:

12.

What were or are you using?

1/ / PILL 2/

f!UD 3/_/DIAPHRAC.'t (2 7.'

4/_/ HYSTERECTOMY 5/ _/TUSES TIED 6/_/0THER:

Specify CODE: /_/_/

(28-29)

First 3 Itrs last name

/ _/ _/_ j__2 / o / (76-80) a6 l

..)

^

~

\\

TMI WORKER REGISTRY CONSENT FORM Background Information In April 1979 the Nuclear Regulatory Commission (NRC) and the National Institute for Occupational Safety and Health (NIOSH) began a cooperative effort to estabitsh a registry of workers at the Three Mile Island (TMI) nuclear facility. The purpose of the registry is to assure that all the necessary information is available for a possible epidemiological study of long-term health effects in workers at this facility. The types of informa-tion needed include medical examination cata, medical history, exposure data, occupational history and some personal ideatifiers.

Since the TMI worker registry is designed to provide data for a possible future epidemiological study of the large TMI worker population, there would be no immediate personal benefit to any particular individual listed in the

~

registry. However, it is hoped that the combined information from many workers' at several facilities would provide information on possible health effects in workers in nuclear industries. This information may eventually benefit the workers listed in the TMI registry, as well as many other. nuclear

]

workers. This type of data would be valuable to the NRC in determining whether

' ~~~

its regulatory policies adequately protect the health of the worker at NRC.

licensed facilities.

You, as a worker, must voluntarily agree to have certain information about l

yourself included in the data for a health effects study.

Metropolitan l

l Edison will consider as confidential all medical and other personal information i

that you provide to them.

If the Federal government proceeds with an epi-

~

demiological study, this information will be considered confidential in t

i accordance with the Privacy Act of 1974 (Public Law 93-579).

Information i

t gathered for the registry will be used for statistical purposes only.

No 1

==

-as e-mm e-.

er w

g_

• me

,,m.,.%

q

.u

2 o

personal information on the workers will ever be disclosed.

~

Consent I have read the above background information on the TMI worker registry and understand the purpose of the registry.

-I. understand that the registry will include information on my medical examinations, medical history, occupational history, radiation exposure records and some personal identifiers (necessary to locate workers in long-term health effects studies).

I understand that my signature on til's form indicates my willingness to provide the information necessary for possible long-term health effects study of the TMI worker population.

All of my present questions about the TMI worker registry have been answered to my satisfaction.

Future que: fons can be directed to the Nuclear Regulatory Commission, Office of Standards Development, Chief, Radiological Health Standards Branch, Washington, D.C.

20555, (301-443-5860).

1

.. t s

j Signature Date A

Name (Please print)

Address

~

1 A copy of this form will be provided for your own reco s

1

.