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Total # of Questions: 13

PhenX - environmental exposures - residential history protocol 060301 [62518-6]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Residence PEG [63725-6]

From what date did you live in the residence? [63726-4]

To what date did you live in the residence? [63727-2]

What is the residence address? Street/Crosstreets City, State or Landmark [63728-0]

Was this on a farm? [63729-8]

What was your water supply? [63730-6]

What was your water supply? [63731-4]

Near fields or orchards? [63732-2]

Did you live close to the center or margin of town? [63733-0]

After the interview has been completed, enter the geocoordinates for the residence. Latitude - [64010-2]

After the interview has been completed, enter the geocoordinates for the residence. Longitude - [64011-0]

Were the geocoordinates verified? [63734-8]

How were the geocoordinates verified? [63735-5]

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