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COMPLETE HEREOMB #: 0925-0406Expiration Date: 08/31/96Agricultural Health StudyAL TLTHROUHGAFarmer Applicator Questionnaire[CODED MANUAL]ST UDYwaNo r t hCaronliaPublic reporting burden for this collection of information is estimated to average 60 minutes per response, includingthe time for reviewing instructions, searching existing data sources, gathering and maintainting the data needed, andcompleting and reviewing the collection of information. Send comments regarding this burden estimate or any otheraspect of this collection of information, including suggestions for reducing this burden, to: PHS Reports ClearanceOfficer, Rm 721-B, Humphrey Building, 200 Independence Ave., SW, Washington, D.C. 20201, ATTN: PRA; andto Office of Management and Budget, Paperwork Reduction Project (0925-0406), Washington, D.C. 20503.Please return this questionnaire in thenext two weeks in the envelope provided.Problems or questions? Call 1-800-4AG-STUDY.
Dear Applicator:We are again asking for your help in carrying out an important scientific study that the University of IowaMedical Center and Survey Research Associates (Durham, NC) are conducting in cooperation with theNational Institutes of Health (NIH) and the Office of Research and Development of the US EnvironmentalProtection Agency (USEPA). The study is being conducted in Iowa and North Carolina and investigatesenvironmental factors, occupation and diet and their effects on an individual's health.Thank you for filling out the Enrollment Questionnaire. Now we are asking you and your spouse tocomplete the main study questionnaires. Questions about your lifestyle, pesticide use, work practices,occupational history, medical history, cooking practices, and health will be asked in more detail than on theform you filled out earlier. Your spouse will be asked questions about family health. You are free to skip anyquestion at any point in the form.The study results will give you information you may find helpful in making decisions for your health andthe health of your family. This information will be provided through the cooperative extension service, stateand county health departments, articles in trade magazines, and public service announcements on radio andTV. You can request study reports by calling the Agricultural Health Study’s toll-free number 1-800-4AG STUDY.Your participation is very important to the success of the study. Information you give us will be treatedwith care and will not be disclosed to anyone but the researchers conducting the study or as required by law.Confidential information like your name and address will be stored in locked files accessible only to studystaff. Your name will not be used in any reports or released in any way. The study results will be reported instatistical summary form only.You may be contacted in the future to take part in related research studies. Your decision to be a part offuture studies will also be voluntary.We need to hear from you within the next two weeks. Please take the time to fill out thisquestionnaire. The booklet may look long but there may be many pages you can skip. Most people find ittakes about an hour to complete. I think you'll find it interesting. Please return the completed form to theAgricultural Health Study Project in the enclosed pre-addressed, postage-paid envelope. Be sure to alsoinclude the Spouse and Female and Family Health questionnaires. If you have any questions about the survey,please contact Pat Miller at the Agricultural Health Study at 1-800-4AG-STUDY.We appreciate your cooperation in this important research project.Sincerely,Michael C.R. Alavanja, Dr. P.H.Project OfficerNational Institutes of HealthPrivacy Act Notification: 42 U.S.C. 285a of the Public Health Service Act authorizes collection of this information. It will be used to evaluate the role of agriculturalexposures and other factors in the development of cancer, neurological disease, birth defects and other chronic diseases. All information is voluntary and a decisionnot to provide all or any part of the requested information will not affect your certification or licensing. The Government may disclose this information to aCongressional Office upon your request, to the Department of Justice in the event of litigation; or to the Government contractors and collaborating researchers whoare analyzing the study data.
DIRECTIONSC Please use a pencil to complete this form.USEN O. 2P E N C ILONLYC Many of the questions will ask you to estimate amounts or to specify a year. We know that you cannot beexact with many of these. We ask that you estimate as best you can when you are not sure.C Be certain to write your answer in the area provided and also completely fill the matching ovals. Erasecompletely if you make any changes.The following kinds of marks will NOT work:The following kind of marks will work:C Mark only one answer to each question except where you are directed to “Mark all that apply.” Do notmake any other marks on this form. If you wish to make comments, please write them under the heading“Additional Comments” at the end of the form.EXAMPLE: To record the response “July 4, ec1020301112131212223413231424YearWrite thenumbers in º 19 9 3boxes.Then fill in ºthe matchingovals beloweach box.23344556625616267172777818288891929991. What is today's date?JanFebMarAprMayJunJulAugSepOctNovDec1215I. General Information[qxday]Month015BEGIN 61626717278182891929[qxyear][a quexdate]YearSAS date1993199419951996-3
2.Over your lifetime, how many years have you lived or worked on a farm?FFFFF3.[ayfarm]Less than 5 years5–10 years11–20 years21–30 yearsOver 30 yearsDuring the last growing season, how many days did you do the following activities?a. Till the soil (plow, disk,cultivate)[algsact1]FFFFFFFFFFNever1–10 days11–30 days31–100 daysMore than 100 daysd. Apply natural fertilizer[algsact4](manure)FFFFFb. Drive combines or othercrop harvesters [algsact2]Never1–5 days6–25 days26–50 daysMore than 50 dayse.Apply chemical fertilizerPlant[algsact3]FFFFFNever1–10 days11–30 days31–100 daysMore than 100 daysf.FFFFFa. Milk cowsFFFFb. Drive trucksFFFFc. Drive diesel tractorsFFFFd. Drive gasoline tractorsFFFFFFFF[algsact6]FFFFFNever1–5 days6–25 days26–50 daysMore than 50 daysA. In the Summer(that is, the growing season)[asmact1]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact2]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact3]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact4]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact5]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)-4 Never1–5 days6–25 days26–50 daysMore than 50 daysHand pick crops[algsact5]4. How often do you personally do thefollowing activities?e. Weldc.Never1–5 days6–25 days26–50 daysMore than 50 daysB. In the Winter(that is, the non-growing season)FFFFFFFFFFFFFFFFFFFF[awnact1]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact2]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact3]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact4]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact5]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)
4. How often do you personally do thefollowing activities?f. Repair enginesFFFFg. Grind metalFFFFh. Grind animal feedFFFFi. Use gasoline for cleaning hands or equipmentj. Use other solvents (like paint stripper,turpentine, benzene) for cleaningk. PaintFFFFFFFFFFFFl. Perform procedures where you may come incontact with animal blood (castration,dehorning, birthing, etc.)5.A. In the Summer(that is, the growing season)FFFFB. In the Winter(that is, the non-growing season)[asmact6]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact7]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact8]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact9]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact10]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact11]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[asmact12]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)FFFFFFFFFFFFFFFFFFFFFFFFFFFF[awnact6]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact7]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact8]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact9]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact10]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact11]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)[awnact12]Never or less than once a monthMonthly (1–3 times a month)Weekly (1–5 times a week)Daily (6–7 times a week)Did a veterinarian ever tell you that any of the livestock on this farm, or any farm you may have worked on, had[aleukdry]leukemia or lymphoma caused by a virus?F No [GO TO QUESTION 8]F YesºA.LIVESTOCKB. IF YES, How many years ago did this first happen?NoYesa. Dairy cattle[aleukst1]FFb. Beef cattle[aleukst2]Fc. Chickens[aleukst3]FLast 5 years6–10 years11–20 years21 or more 5
6.How many different times has viral leukemia or lymphoma been diagnosed on the farm?a. Dairy or Beef Cattleb. 9100–199200 or moreDon’t know[atotinf]How many years have you been told that all or part ofthe crops grown or stored on your farm had aspergillus[aasperg](aflatoxin B)?FFFFF9.NeverOnceTwiceThree timesFour timesFive or more timesDon’t knowIn total, how many animals have been diagnosed with viral leukemia or lymphoma (include cattle and Three timesFour timesFive or more timesDon’t knowNever1 year2 years3 or more yearsDon’t knowHow many years have you been unable to harvest or sell all or part of the crops grown or stored on your farm[amolds]because of molds other than aspergillus?FFFFFNever1 year2 years3 or more yearsDon’t knowII. Pesticide Use Information10.What application methods do you generally use when you apply herbicides? (Mark all that apply.)FFFFFFFFFDon’t usually apply herbicidesAirblastBoom on tractor, truck, or trailerHand spray gunBackpack sprayerAerial (aircraft application)In furrow or bandedMist hrbmth9]DO NOT WRITE OUTSIDE BOX-6
11. What application methods do you generally usewhen you apply crop insecticides? (Mark all thatapply.)FFFFFFFFFDon’t usually apply crop insecticidesAirblastBoom on tractor, truck, or trailerHand spray gunBackpack sprayerAerial (aircraft application)In furrow or bandedMist blower/foggerOther15. When you personally mix herbicides, whatadditives do you generally use? (Mark all nsmth9]FFFFFF12. What application methods do you generally usewhen you apply poultry/livestock/animalconfinement area insecticides? (Mark all that apply.)F Don’t usually apply poultry/livestock/animalconfinement area insecticidesEar tagHang pest strips in barnDust animalsFog/mist animalsDip animals in pesticide solutionSpray animalsSpray buildingsRope wickPour on 10][acaimt11]insecticidesF Don’t usually use additivesF Solvents (like diesel fuel)F Other ngmt9]14. What application methods do you generally usewhen you apply fumigants? (Mark all that apply.)Don’t usually apply fumigantsGas canisterRow add4]18. When you personally mix fungicides, whatadditives do you generally use? (Mark all thatapply.)DO NOT WRITE OUTSIDE nsadd5][ainsadd6]F Don’t mix animal/livestock/animal confinement area13. What application methods do you generally usewhen you apply fungicides? (Mark all that apply.)Don’t usually apply fungicidesAirblastBoom on tractor, truck, or trailerHand spray gunBackpack sprayerAerial (aircraft application)Pre-applied to seedMist blower/foggerOtherDon’t mix crop insecticidesDon’t usually use additivesSolvents (like diesel fuel)FertilizerOther pesticidesSurfactants, crop oil concentrates17. When you personally mix animal/livestock/animalconfinement area insecticides, what additives doyou generally use? (Mark all that apply.)DO NOT WRITE OUTSIDE 4][ahrbadd5][ahrbadd6]16. When you personally mix crop insecticides, whatadditives do you generally use? (Mark all thatapply.)DO NOT WRITE OUTSIDE BOXFFFFFFFFFFDon’t mix herbicidesDon’t usually use additivesSolvents (like diesel fuel)FertilizerOther pesticidesSurfactants, crop oil 4]DO NOT WRITE OUTSIDE BOX-7 Don’t mix fungicidesDon’t usually use additivesSolvents (like diesel fuel)FertilizerOther pesticidesSurfactants, crop oil 4][afungad5][afungad6]
For the following pesticides, first answer the question in Column A. If you answered “Yes” then answer the questions inColumns B, C and D for that pesticide. If you answered “No” then go on to the next pesticide. Be sure to answerColumn A (“Yes” or “No”) for each pesticide listed. This list includes some pesticides that are no longer on the market.Please answer about your use of these pesticides in past operations.Name of PesticideA.Have you everpersonally mixedor applied thispesticide?B.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?D.When did you firstpersonally use thispesticide?19. Herbicides (pesticides used to kill weeds)[a herbicide cd4]F No F Yesººa. Classic or otherchlorimuron ethylproducts[a herbicide day4][a herbicide fu4]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr4]F Mark here if you usedthis pesticide last year[a herbicide ls4][a herbicide cd8]F No F Yesººb. Lexone, Sencor orother metribuzinproducts[a herbicide day8][a herbicide fu8]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr8]F Mark here if you usedthis pesticide last year[a herbicide ls8]c. Paraquat[a herbicide cd9]F No F Yesºº[a herbicide day9][a herbicide fu9]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr9]F Mark here if you usedthis pesticide last year[a herbicide ls9]d. Petroleum oil/petroleum distillate[a herbicide day10][a herbicide fu10]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr10]º[a herbicide cd10]F Mark here if you usedthis pesticide last year[a herbicide ls10]-8
Name of Pesticidee. Prowl or otherpendimethalin productsA.Have you everpersonally mixedor applied thispesticide?B.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?D.When did you firstpersonally use thispesticide?[a herbicide day11][a herbicide fu11]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr11]º[a herbicide cd11]F Mark here if you usedthis pesticide last year[a herbicide ls11]f. Sutan, Genate or otherbutylate products[a herbicide day15][a herbicide fu15]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a herbicide yr15]º[a herbicide cd15]F Mark here if you usedthis pesticide last year[a herbicide ls15][a herbicide cd14][a herbicide yr14][a herbicide day14][a herbicide fu14]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sh. 2,4,5 T[a herbicide cd18][a herbicide yr18][a herbicide day18][a herbicide fu18]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºg. Silvex or other2,4,5 T P productsº-9
Name of PesticideA.Have you everpersonally mixedor applied thispesticide?B.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?D.When did you firstpersonally use thispesticide?20. Crop/Livestock/Animal Confinement Area Insecticidesa. Forlin, Gamaphex orother lindane products[a insecticide day6][a insecticide fu6]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a insecticide yr6]º[a insecticide cd6]F Mark here if you usedthis pesticide last yearb. Malathion[a insecticide day9]F No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 days[a insecticide ls6][a insecticide fu9]F Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a insecticide yr9]º[a insecticide cd9]F Mark here if you usedthis pesticide last yearc. Parathion (ethyl ormethyl)[a insecticide cd10] [a insecticide yr10]F No F YesººF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 days[a insecticide ls9][a insecticide fu10]F Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 years[a insecticide day10]F Mark here if you usedthis pesticide last yeard. Sevin, Carbamine orother carbaryl products[a insecticide cd11] [a insecticide yr11]F No F YesººF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 years[a insecticide day11]F Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 days[a insecticide ls10][a insecticide fu11]F Mark here if you usedthis pesticide last yeare. Spectricide, Dianon orother diazinon products[a insecticide cd12] [a insecticide yr12]F No F YesººF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 years[a insecticide day12]F Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºF Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 days[a insecticide ls11][a insecticide fu12]F Mark here if you usedthis pesticide last year[a insecticide ls12]- 10
Name of Pesticidef. Temik or other aldicarbproductsA.Have you everpersonally mixedor applied thispesticide?B.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?[a insecticide cd13] [a insecticide yr13]F No F Yesºº[a insecticide day13][a insecticide fu13]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsD.When did you firstpersonally use thispesticide?F Mark here if you usedthis pesticide last year[a insecticide ls13]g. Thimet, Rampart orother phorate products[a insecticide cd14] [a insecticide yr14]F No F Yesºº[a insecticide day14][a insecticide fu14]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Mark here if you usedthis pesticide last year[a insecticide ls14]h. Aldrin[a insecticide cd15] [a insecticide yr15]i. Chlordane[a insecticide cd16] [a insecticide yr16]j. Dieldrin[a insecticide cd17] [a insecticide yr17]k. DDT[a insecticide cd18] [a insecticide yr18]F No F YesººF No F YesººF No F YesººF No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 years- 11 [a insecticide day15][a insecticide fu15]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a insecticide day16][a insecticide fu16]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a insecticide day17][a insecticide fu17]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a insecticide day18][a insecticide fu18]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s
Name of PesticideA.Have you everpersonally mixedor applied thispesticide?B.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?l. Heptachlor[a insecticide cd19] [a insecticide yr19]m. Toxaphene[a insecticide cd20] [a insecticide yr20]F No F YesººF No F YesºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsºF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsD.When did you firstpersonally use thispesticide?[a insecticide day19][a insecticide fu19]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a insecticide day20][a insecticide fu20]F Less than 5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s21. Fungicides (chemicals for controlling disease on crops and seed; may be pre-applied to seed)a. Benlate, Tersan orother benomyl products[a fungicide cd1]F No F YesººF No F Yesº[a fungicide fu1]F Pre-applied to seedF NoneF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a fungicide yr4][a fungicide day4][a fungicide fu4]F Already applied toF Pre-applied to seedF NoneF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a fungicide yr5][a fungicide day5][a fungicide fu5]F Already applied toF Pre-applied to seedF NoneF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sseedF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsseedF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 years- 12 this pesticide last year[a fungicide ls1]F Mark here if you usedthis pesticide last year[a fungicide ls4]ºseedF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF Mark here if you usedº[a fungicide cd5][a fungicide day1]F Already applied toºF No F Yesººc. Ridomil, Subdue orother metalaxylproducts[a fungicide cd4]ºb. Manex, Manzate,Dithane Z-78 or othermaneb or mancozebproducts[a fungicide yr1]F Mark here if you usedthis pesticide last year[a fungicide ls5]
Name of Pesticided. Zirex, Corozate orother ziram productsA.Have you everpersonally mixedor applied thispesticide?[a fungicide cd6]F No F YesºB.C.How many years did In an average year whenyou personally mix or you personally used thisapply this pesticide?pesticide, how manydays did you use it?D.When did you firstpersonally use thispesticide?º[a fungicide day6][a fungicide fu6]F Already applied toF Pre-applied to seedF NoneF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sseedF 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsº[a fungicide yr6]F Mark here if you usedthis pesticide last year[a fungicide ls6]22. Fumigants (gases or liquids that turn to gas when released; used in enclosed areas or to treat soil)[a fumigant cd2]F No F Yesººa. Phostoxin, Gastoxin orother aluminumphosphide products[a fumigant day2][a fumigant fu2]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990sº[a fumigant yr2]F Mark here if you usedthis pesticide last year[a fumigant ls2]b. Carbon tetrachloride/carbon disulfide(80/20 mix)[a fumigant cd3]c. EDB, E-D-Bee,Bromofume or otherethylene dibromideproducts[a fumigant cd4]F No F YesººF No F Yesºº[a fumigant yr3][a fumigant day3][a fumigant fu3]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s[a fumigant yr4][a fumigant day4][a fumigant fu4]F 1 year or lessF 2–5 yearsF 6–10 yearsF 11–20 yearsF More than 20 yearsF 1 dayF 2–5 daysF 5–9 daysF 10–19 daysF 20–39 daysF 40–59 daysF 60–150 daysF More than 150 daysF Before 1960F In the 1960sF In the 1970sF In the 1980sF In the 1990s- 13
23. In your lifetime, other than those listed above, have you personally used any other pesticides frequently (either now[aothrpcd]or in past years)?F No [GO TO QUESTION 25]F Yes [CONTINUE]º24. What other pesticides have you used frequently (either now or in the past)? (Mark all that you have used.)A. Crop InsecticidesFFFFFFFFFFFFFAastar (flucythrinate phorate)Broot (trimethacarb)Cygon 400 (dimethoate)Delnav (dioxathion)Dipel (bacillus thuringiensis)Di-syston (disulfoton)Etrolene, Korlan, Ronnel (fenchlorphos)Force (tefluthrin)Guthion (azinphos methyl)Imidan (phosmet)Kelthane (dicofol)Lannate (methomyl)Lead os)Mocap (ethoprop)Noxfish (rotenone)Orthene (acephate)Phosdrin (mevinphos)Pydrin (fenvalerate)Ruelene (crufomate)Thiodan (endosulfan)Totalene, Tugon (trichlorfon)Vydate 6]FFFFFFStimukil (methomyl)Neguvon, Tugon (trichlorfon)Prolate (phosmet)Rabon, Gradona (tetrachlorvinphos)Rotenone ][aohrb4]FFFFFFFFFFFFFFFFFHoelon (diclofop-methyl)Inorganic ArsenicLorox (linuron)Marksman (dicamba atrazine)Paarlan (isopropalin)Princep (simazine)Organic ArsenicPoast (sethoxydim)Ramrod (propachlor)Scepter (imazaquin)Sonalan (ethalfluralin)Squadron (pendimethalin imazaquin)Surflan (oryzalin)Sutazine (atrazine butylate)Tandem (tridiphene)Vernam (vernolate)Zorial (no
DIRECTIONS C Please use a pencil to complete this form. C Many of the questions will ask you to estimate amounts or to specify a year. We know that you cannot be exact with many of these. We ask that you estimate as best you can when you are not sure. C Be certain to write your answer in the area provided and also completely fill the matching ovals.
