STUDY OF TOXIC WASTE
Questionnaire for EpidemiologicalStudy
November 2006
Identification(to fill in by the supervisor)
1-Commune ………………………… .2-Neighborhood …………………
3-N° ofHousehold: /___/___/___/___/ 4-GPS position: …………………
Firstseries of questions(to be administered by theteam leader)
Message 1: (introductionof the interview)
Q1 Quality of investigated person: head of household /__/ Wife /__/ Eldest son /__/ other /__/
Q2 If other, please specify……………………………………………
Q3 Age of investigated person(in years /__/__/)
Q4 Has your household been affected by toxic waste? Yes /___/ No /___/
If not, end of interview
Q5Number of personsliving in the household: /___/___/
Message 2: (introductionof the censusof household members)
ANNEX A: Identification ofhousehold members
Identification (to fill in by the supervisor)
1-Commune …………………………… 2-Neighbourhood …………………
3-N° of Househod: /___/___/___/___/ 4-GPSposition: …………
Secondset of questions(to be administered by thehealth worker, starting withthe head of household)
Message 3: (introduction to tableA)
Tableau A
A1 N° Member / A2 Age / A3 SexF/M / A4 Position
(siblings) / A5 Profession / A6
Level of education / A7
Present at time ofdischarge
Y/N / A8
Did he/she have signs of intoxication?
Y/N
1
2
3
4
5
6
7
8
9
10
Message 4:(introductionofimpact issues)
Thirdset of questions(to be completedbythe health worker)
Q6 Did you have tomove outof your homebecause of thetoxic waste?
Yes /__/ No /__ /(if notgo toQ10)
Q7 If so, where did you go? ......
Q8 What were the expenses of this move?......
Q9Did the toxic waste lead to other problems in the household? Yes / __ / No / __ /
Q10 If yes, please specify.……………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………………….
…………………………………………………………………………………………….
Q11How did you deal with these problems?
Did you receive support of your family? Yes / __ / No / __ /
Did you receive state aid? Yes / __ / No / __ /
Or aid of other institutions? Yes / __ / No / __ /
Q12 Did the measures taken by the authority (destruction of fields, poultry, livestock, etc.) affect you? Yes / __ / No / __ /
Q13 If yes, please specify
…………………………………………………………………………………………
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
Q14 How is the family today?
- In terms of health? good / __ / bad / __ /
- The a social point of view?good / __ / bad/ __ /
- In terms of finances? good / __ /bad / __ /
- The economic point of view? good / __ / bad / __ /
Q15Do you have other comments or statements?
......
…………………………………………………………………………………………….
…………………………………………………………………………………………….
……………………………………………………………………………………………..
ANNEX B: Symptoms experiencedby sick person
Identification (to fill in by the supervisor)
1-Commune ………………………… . 2-Neighbourhood ……………………
3-N° of Household: /___/___/___/___/ 4-GPS position: ……………………..
Fourthseries of questions(to be administered by a doctorto each intoxicated person)
Message 5:(reception andfillin TableB)
Table B
B1 Number (cf. Table A):…………………………………………………….
B2How did you feel after contact with the waste? Check the boxesin column"b"corresponding to thesymptomsmentioned by the interviewee.
B3Did you suffer from one of the following signs? Fill in column "c" by prompting symptoms of column "a"
a) Symptoms / b) spontaneous responsesY/N / c)prompted responses
Y/N
headache
dizziness
drowsiness
asthenia
throat irritation
cough
chest pain
tingling
breathlessness
itching
burns
photophobia
abdominal pains
nausea
emesis
throat ache
eye pain
unconsciousness
bleeding from nose
nasal discharge
breathing difficulty
lacrymation
conjunctivitis
Other, please specify
B4Have youconsulted in ahealth centre or health facility? Yes /__/ No /__/
B5 If yes, which one?......
B6What treatmentdid you receive? Drug donation?Yes /__/ No /__ /; medical prescriptionYes /__/ No /__ /; hospitalisationYes /__/ No /__ /
B7Areyouhealthy now?Yes /__/ No /__ /
B8) If not,whatare you sufferingnow?......
ANNEXC:Clinical signs in people whostill sufferfrom toxic waste exposures
Identification (to fill in by the supervisor)
1-Commune ………………………… . 2-Neighbourhood …………………
3-N° of Househod: /___/___/___/___/ 4-GPS position: …………………….
Table C:(to be filled with people who are now signs of intoxication)
Message 6:(introduction to clinical examination)
C1) Patient ID No. :……………………………………….
General condition / asthenia
impaired consciousness
coma
dehydration
cardiovascular collapse
ORL / rhinitis
epistaxis
pulmonary / cough
dyspnoea
pneumopathy
ocular / lacrymation
conjunctivitis
digestive / throatache
abdominal pain
nausea
emesis
cutaneous / pruritis
dermatitis
ANNEXD: Messages
Message 1: We are researcher from CSRS and conduct a study on impact of toxic waste which was deposited in this area. We would like to meet with the head of your household and have a small discussion.
Message 1a: we are researcher from CSRS and we do a study on toxic waste. In this context we want to ask you just a few short questions.
Message 2: Well! I'll leave you with my colleague who will ask you for information about people who live in the household.
Message 3: During our conversation I will ask some people to go to my colleague for more information.
Message 4: Now we would like to discuss with you the consequences of this toxic waste event on your household.
Message 5: You have been sent to me because you have suffered the effects of toxic waste.
Message 6: As you continue to suffer, I would like to obtain more information about your condition in order to understand the situation better.