Consent to Participate in a Research Study You are invited to participate in the Marin Women?s Study, a research study conducted by the Marin County Department of Health and Human Services. Other participating institutions include Buck Institute forAge Research, Fred Hutchinson Cancer Center, Kaiser Permanente San Rafael Medical Center, Marin General Hospital, Novato Community Hospital, University of California, San Francisco (UCSF) and Zero Breast Cancer. The study is sponsored by the Centers for Disease Control and Prevention (CDC). STUDY PURPOSE: The purpose of the Marin Women?s Study is to establish a data collection registry that includes individual risk factor and biologic data about women living in Marin County. The results of the study will be Used to try to answer questions about how breast cancer is influenced by lifestyle and biologic factors. You are being invited to participate in the study because you live in Marin County and will be having a mammogram as part of your routine health care. We estimate 20,000 Marin County women getting mammograms wilt be participating in this study. . STUDY PROCEDURES: If you agree to be in the study and sign this consent form, you will be asked to do the following: (1) Complete a questionnaire Complete the attached questionnaire. It will ask you questions about aspects of your family and medical history and lifestyle factors that may be important in breast cancer. Please mail the completed questionnaire in the postage-paid return envelope or bring it with you to your appointment. Completing the questionnaire should take 20-40 minutes. (2) Give a saliva sample Some women will be randomly selected to donate a saliva sample. If you are asked to donate a saliva sample, a coiiection kit with instructions will be provided to you. Giving the saliva sample (about two teaspoons) invoives spitting into a plastic vial and mailing the collection kit in the postage?paid envelope provided to you. Participation in this study should take less than 1 hour. USE OF SALIVA SAMPLE: if you agree, your saliva sampie may be used to examine genes and gene expression and other factors that may be important in breast cancer diagnosis. This information will only be used for research purposes. Because this is a rapidiy changing field, we are not certain exactly which genes or gene profiles researchers may want to study in the future. Since this information wili not be used as part of your medical care, individual resuits wiil not be shared with you, your doctor, or anyone outside the Marin Women?s Study. FUTURE RESEARCH: In the future, other substances or genes may be discovered that may affect women?s health, and your saliva sample will be stored in a locked freezer for future use. in the event your sample is used, you not be contacted for permission to use your sample, however, confidentiality and privacy protections will be maintained. CONFIDENTIALITY: The researchers will keep information about you obtained for this study confidential. Your name and individual information will not appear in any report of study results. However, representatives of the Marin General Hospital Institutional Review Board (a formal committee that reviews research studies to protect the rights and welfare of participants) and other regulatory agencies may review research records to ensure the protection of study participants. LINKING DATA TO THE SAN FRANCISCO MAMMOGRAPHY REGISTRY: In order to examine the associations between risk factors and breast the data in this study will be linked to the San Francisco Mammography Registry (SFMR) databas??iigin'Ce per year. The SFMR is a mammography registry created by doctors and scientists at the University of California, San Francisco to learn more about mammograms. ,#990000 p-w1_233997 DISCOMFORTS AND RISKS: Some of the questions in the questionnaire may make you feel uncomfortabie. You have the right to refuse to answer any question if you wish to do so. Providing us with a saliva sample by spitting into a plastic vial has no known risk. BENEFITS: You will not receive any direct benefits from participating in this study. We hope that knowledge gained from this study will lead to a better understanding of the causes of breast cancer and to its prevention in the future. We also hope you will gain a sense of satisfaction for contributing to this research. VOLUNTARY Your participation is entirely voluntary. If you do enroll in the study, you will always have the right to withdraw at any time, to refuse to answer any particular question, and/or to not provide a saliva sample. Your decision will not affect your medical care now or in the future. CONTACT FOR FUTURE RESEARCH: We may want to contact you to ask additional questions or to collect additionai saliva samples for future research questions. If we contact you in the future, you can decide then whether or not to participate. QUESTIONS: Any study-related questions or problems should be directed to the investigator responsible for the study at the Marin County Department of Public Health, Rochelle Ereman, MS, MPH, RD, at 507-4077. Questions about your rights as a study participant, or comments or complaints about the study also may be presented to the Marin General Hospitai lnstitutionai Review Board, 1350 South Eliseo Drive, Greenbrae, CA 94903, telephone (415) 925-7965. it - I agree to complete the questionnaire Yes C) No (initials) (initiate) I agree to ailow my data to be linked with the results of the mammography(The San Francisco Mammography Registry) (Ma's) . ('"it'a'si .- i agree to donate a saiiva sample Yes C) No (initials) (initials) it; I agree to be contacted for future research Yes No C) gsaGNm5waiteras:mg; ?fit?Li?iJ'rii Signature of Study Participant Date Printed Name of Study Participant tor-vows alternate: 'db'rita?'t's' entact?ng Preferred contact methOd: 0 phone: (3 mail: C) email address: Alternate Contact #1 Alternate Contact #2 Alternate Contact #3 I i- 1= . Authorization to Use and Disclose Protected Health Information Why is this authorization required? I The Privacy Rule is a federal law designed to safeguard your Protected Health Information (PHI). Y0ur PHI is individually identifiable information about you, including your physical or mental health, the receipt of health care, or payment for that care. The Privacy Rule requires that researchers obtain your written authorization for you to participate in this study. By signing this authorization, you will permit your hospital to use and disclose your PHI for the purpose of the research study named above. Your will only be used and disclosed as described in this authorization, except as otherwise required by law. Must I agree to this authorization in order to participate in the research? Yes, in order to participate in this research study, you must agree to the uses and disclosures of your. PHI as described in this authorization. - Who will use or disclose my Your hospital and the Marin County Department of Health and Human Services researchers will use your PHI only for the purposes of this study. will not be disclosed to individuals or institutions not participating in the study. What is the purpose of the use or disclosure of my - Your hospital and the researchers will use your'PHl, including your research record, to conduct the study and determine results. In addition, others at your hospital, for example, the Institutionai Review Board that approved the study, may also review your research record, to monitor the progress and safety of the study. Information from your research record and medical record used and disclosed for the study may include, for example, both clinical and research observations relating to your participation in the study. When will this authorization expire? This authorization will expire at the end of this research study. Can I withdraw this authorization? Yes, at any time during this study you may decide that you no longer want to have yoUr PHI used or disclosed as part of this study. If so, you must write a letter stating that you withdraw your authorization and send it to: Rochelle Ereman, MS, MPH, RD - Marin County Department of Health and Human Services - 20 North San Pedro Road, Suite 2002 San Rafael, CA 94903 If you withdraw your authorization, you may be required to end your participation in the study. researchers may continue to use your that was obtained before you withdrew your authorization. Your hospital will not disclose your PHI after they receive your written request except as required by law. For example, even if you withdraw your authorization, your hospital may be required by law to record and report anything that relates to your safety or the safety of others. - Will I get a copy of this authorization? You may make a copy of this authorization. Sig attire 'f-3'13PaitiCipa'ntIN. AREA -. YOU FOR PARTICIPATING IN THE MARIN 0 Some questions ask you about things that happened at different time periods throughout your life. We understand that it is difficult to remember things that occurred in the past, so please give us your best estimate. . Use black or blue pen or a number 2 pencil. MARKING INSTRUCTIONS - Make dark marks that fill the oval completely. - Do not use pens with ink that soaks through the paper. - Make no stray marks. 9999 Correct marks 62') (Z) G) Incorrect marks EXAMPLE Fill in here AND {?Fill in bubbles below number or letter. @9660 as ?see-1e:ece messes so: 4-: .. lease-sas? ~o If you have any additional comments or explanations, please feel free to write them on a separate piece of paper. If you have any questions about or need help with the questionnaire, call the Marin County Department of Health and Human Services at 415-507-4077 or send an email to marinepi@co.marin.ca.us. i ?7o 2339973?@?? .. . Do NOT WRITEIN THIS AREA 5 SERVICES. OF HEALTH AND HUMAN THIS PAGE WILL BE REMOVED FROM YOUR QUESTIONNAIRE AT THE MARIN COUNTY DEPARTMENT '@6699 a 8? 3.. 'izm . . .. . ?an; H6666 666666666666666m .66666666666666 6.6 6'6 @6666 666666 @6666666696666666666 66666666666666666666 06666666666666666666.8 6 666666666666666666666 666666666666666666666m_6666 666666666666666666666666666 Q66666666666666666666666666 @66666668966868 6666666666668? @66666669666366666666666 i666666666666666666666666 66666666666666666666666 '66666666666666666666666 66666666666666666666666 66666666666666666666666 66666666666666666666666 66666666666866666666666 66666666666666666666666 66666666666666666666666 66666666666666666666666 66666666666666666666666 66666666666666666666666 666666666666666666666666 06666666M .666666666666666666666666 666666606 @6666 1. Today's date The following are some general questions about you. When combined with the answers of other women completing the questionnaire, they will write_m_> 2008 0 help us learn about the characteristics of the 2009 0 women In this study. AND (30 are) 2010 . 5. What is your date of birth? flunk? @e . bubbles . g: I 1 9 write-in ?3 2C2bubbles . . I 2. What do you think 15 causmg the high breast cancer rates in Mann County? . (mark all that apply) @153 8 E-e Fadors 6. Racial or ethnic background: C) Environment (fill in all that apply) Demographics (such as age, race, and income) C) Genetics C) African?American Black C) {Lapanese C) Don?t know C) Caucasian/ White 0 i ina C) Other (please specify): C) Hispanic Latina Vie amese American Indian Other Asian C) Chinese 0 Other, non-Asian I inherited forms of breast cancer are more 3 Where are on e?in this mammo ram? common in Ashkenazi Jewish families or Jewish 3 - families from Central or Eastern Europe. C) Breast Diagnostic Center, Marin General Hospital . 7. Do you have Jewish ancestry? Novato Community Hos ital 0 Kaiser Downtown, San afael NO - Skip. to Q9 0 Don?t know (3 Kaiser Novato YES 0 Kaiser Terra Linda, San Rafael C) Thermogram Location 8 8. Do you have Ashkenazi Jewish ancestry? I Kaiser Sonoma County 0 NO C) Don?t know C) Other: C) YES . . 9. What is the total number of years you have lived in Marin County? Please select the clo st number ears. 4. Why are you gettmg this mammogram? 5e 0 C) Routine screening C) Follow-up for breast abnormality C) Other (please specify): write?in AND C) Don?t know fill in bubbles @6398 @9869 :52 2 I I I. I 3 10. How many years did you attend school in Marin County during each of the following periods of time? C) Did not attend school in Marin County Preschool (2) Grade school (grades ages 5-12) (E) (D (Z) (3 (3 Name (Grade schoo!) Middle and High school (grades 7?12, ages 13?18) Name (Middle school) (D (3 Name (High school) College Trade school (Ages 19?21) (D (E) (3) G) (S) College/ Trade school (After age 21) G). (3) 11. What is your marital status? C) Married C) Living to ether with a partner C) Widowec? C) Divorced C) Separated CD Single and was never married BREAST HEALTH HISTORY 12. Have you ever had a breast biopsy'lf ES, how many biopsies have you had. 635(3) (Dc) .- 13. What were the diagnoses? (mark all that apply) Invasive breast cancer C) Ductal carcinoma in?situ (DCIS Lobular carcinoma in situ (LCI C) Atypical hygerpiasia C) Fibrocystic isease C) Benign Not sure C) Other (please specify): 14. Has a doctor ever told you that you have breast cancer? C) NO 0 YES How old were you when you were first diagnosed. (inn @213 @256) @263) 2 G) REPRODUCTIVE HISTORY Reproductive patterns have been associated with breast cancer. The next set of questions will help us learn more about reproductive patterns in Marin women. 15. 16. 17. How old were you when your periods started? Please give us your best estimate. 8 or less C312 015 C318 (310 C) 13 (316 How many times have you been pregnant, including pregnancies that ended in abortions, ectopic pregnancies, or miscarriages? 89 8 El 9 How many children have you given birth to? Please include stillbirths (pregnancy lasting more than 20 weeks), but do not include miscarriages (pregnancy ending at 20 weeks or earlier remains? - . Js-w?gw?wx was 18. Now consider pregnancies that resulted in a live birth. For each birth please tell us: how old you were when each child was born, how many months you breastfed each child if at all, if the child was born early, their birthweight, your approximate weight gain during the pregnancy, and whether you had high blood pressure at any time during the pregnancyBrood P-fss'suregpuring 3? weeks early 5- weeks early No 1% weeks early 8 8 weeks early 9969.99 5:3- i "fiBiahw?ightl: Low 51/2 2500 grams) C) High 9 4000 grams) C) Nelther 9 95.9 Q9 99 a? @969 (9 56?) (-326) C) YES NO . .. Pressure Pregnancy- 2 . Low 51/2 lbs/ 2500 grams) C) High 9 #1000 grams) C) Neither aha-@569 @99886} @5a .89 90; @319 8.9 C) YES NO \Breastfedi :g?xggnancy 5. Pressure. Dari-11.1.8 Birthweigh't :1 '2 C) Low 51/2 lbs/ 2500 grams) 0 High 9 4000 grams) C) Nelther C) YES C) NO PLEASE no Not wane Jun-its am *r 3 ?1 233997 1 ~EQ?Io?popl 213 . i'ght .. Months .. - - -. . . No 1?2 weeks early 3-4 weeks early G). 5-8 weeks early @303 8 weeks early LCD .Low 51/2 2500 grains) C) High 9 lbs/4000 grams) j? C) Nelther G) i 19. Did you ever use birth control pills (oral contraceptives) for one month or longer for 20. 21. 22. any reasonYES Are you currently us C) NO C) YES How old were you when you first used birth control pills? And how old were you when you last used them? 23. Was there ever a time in your life when you tried for at least 1 year to become pregnant and could not? NO YES ing birth control pills? 24. Did you ever take any of the following fertility drugs to try to become pregnant? (mark all that apply) C) None Pergonal C) Clomid Danocrine C) HCG C) Danazol C) Lupron Depot C) arel Nasal Solution thenfplease ecify: ert C) ltook ility don?t remem er $39 the name(s)- 53$) G) 25. Have your menstrual periods stopped G336) permanently? If so;r at what age? CECE) C) No G) C) Not sure, periods less frequent C) Yes: Periods stopped naturally C) Yes: But now have periods induced by (2) hormones C) Yes: Uterus removed by surgery G) Yes: Uterus and both ovaries removed by surger Yes: 0 her: HOW many Years in No'of Years? lf Yes Hei'Pe?Ods "ed totalhaveyouused g. . birth control pills (Add together the years when you used birth control pills - exclude those 'ods if ?335? Pen I an}? when you temporarlly 7 .16) (322(3) stopped). @226) 3 '5 I law? .5 m; a'oc. \11 . am?" sue?1'. . 26. Have you ever used hormone replacement therapy (HRT) for of menopause or for other reasons? (mark all that apply) 28. Please describe any menopause you had at the onset of menopause. Did not have Started taking ormone therapy before having any NO Skip to Q28 YES Prescri tion medication . C) YES Over- e?counter None Severe (?On-Prescription) Hot?ashes . . Night'sw?ats 27- What are the main reason(s) you . . started usrng hormone therapy? LOSS of sex drive E) G) (E Uterus and/or ovaries removed Menolpausal Mood swings, depression (E) (Z) (3) GD (5) Healt I 1 0 Cosmetic reasons Urinary 69 6) Ci) (D G) Other: . . .. Other: a "mam 29. Are you currently using any of the 32. During the past 5 years, have you used any 30. 31. following natural hormone supplements on a regular basis (at least once a week)? (mark all that apply) C) None - Skip to Q32 0 Combination herbal remedies (ex. Estroven and Estrohealth) C) Black cohosh Chaste tree or berry C) Dong Quai C) Phytoestro gens plant estrogens C) So supplements C) W1 yam C) Other (please specify): Please estimate the total length of time you have used these natural hormone supplements. C) 1 year C) 3?4 years C) 1-2 years C) 5+ years What is the main reason(s) you are using the natural hormone supplements? (mark all that apply) C) Menopausal mptoms C) Replacement or prescri tion hormone replacement therapy T) Prescription HRT not help my C) Pre?Menstrual (PMS) C) Hysterectomy ovary removal Concerns about breast cancer C) Prescribed or recommended by my ractitioner C) ther (please specify): 33. 34. other natural hormone supplements at least weekly for 3 or more months in a row? (mark all that apply) None Skip to Q35 CD Combination herbal remedies (ex. Estroven and Estrohealth) C) Black cohosh Chaste tree or berry Dong Quai Phytoestrogens plant estrogens C) 80 supplements C) W1 yarn C) Other (please specify): Please estimate the total length of time you used these natural hormone supplements. 1 year C) 3-4 years 0 1?2 years 5 years What was the main reason(s) you used the natural hormone supplements? (mark all that apply) CI) Menopausal mptoms C) Replacement or prescg?tion hormone replacement thera T) C) Prescription HRT did not help my 0 Pre-Menstrual (PMS) C) Hysterectomy ovary removal Concerns about breast cancer 0 Prescribed or recommended by my practitioner Other (please specify): ?s 3s . 35. What menopausal are you If the next 3 tables do not capture your experiencing currently? Please rank your hormone therapy usage, please provide any on a scale from 1 (mild) to 5 (severe). additional information here: None Mild Severe -39" ?ashers. ?3 :3 .. Ca) vac-I. arc.- Curr. Loss of sex drive Mood swings, depression . I Urinary. .. dud . I Other: I I a a 36. Please fill out the following tables for each type of hormone therapy you have taken for menopause. Please list each type separately. Have not taken hormone therapy for menopause Skip not remember when you started or stopped, your best guess is better than no answer at all. Minx-mu sir-am, was-am. Progestin? an cww??uckw' not?wees; mam. maul??! .-7 C) Still taking Estrogen only C) 2 gills Patch only Pill patch C) Cream Shot C) Shot patch C) Va ma ring C) 0 er: Progestin only Estrogen and Progestin C) Other: (D a) a) .6552. warm-2m 6 . a ?mu-Ha (.53 man: Don?t know C) Natural Estrogen 9:9 @143 938 9@563 8 Don?t know a 013?? 9.19 @8989 a 8 (9 (9 9 Less than men C) Natural Progestin Testosterone ma: mus-arcadm?m Currently taking Health risks C) Replaced with non? rescri tion medications ide ef ects C) News reports C) Doctor recommended C) Switched type of HRT 0 Not needed C) Hysterectomy Got breast cancer Other: i Estrogens Estrogen Progestin C) Premarin Estrin ProgESth C) Provera C) 0 en (3 Estra 101 C) Prempro C) Prometrium . C) Es ace (3 Menest C) Premphase C) Natural Erogestm C) Vagifem C) Bi-est Other: C) Other: C) Vivelle Climera 3'31 2.29;: C) Other: 0 Other: 3. (rt-Form?- .. r. 3 {Age stopped} C) 1 pill C) Still taking 2 pills C) Patch only (E) C) Progestin only 0 Pill patch 0 Cream @123 C) Estrogen and Progestin 0 Shot - C) Shot atch C) Other: C) Va ina ring C) er: G) i C) Don?t know Don?t know (DC) C) Natural Estrogen 0 Natural Progestin M-ark-all-that-?a 'l an (. . .ppy) . Testosterone monthl 0 Currently taking Daily C) Health Replaced with non- rescri tion medications em}: 0 News reports Estrogens Estrogen 82: Progestln Doctor recommended Premarin Estrin Progealns C) Provera. C) Switched type of HRT Ogen C) Estra 101 CI) Prempro Prometrlum C) Not neede Estrace C) Menest C) Premphase Natural Progestln Hysterectomy C) Vagifem C) Bi?est C) Other: Other: Got breast cancer 0 Vivelle C) Ciimera C) Other: C) Other: :gs Ilsahl' ., titted . .. . days:armortth?drdteyouFuse 8 ?pll C) Still taking C) Estrogen only EStmgen? PrOgEStm? 1 only Progestin only Pill patch CDCD Cream Estrogen and Progestin g? C) Shot a) (Do) C) Shot patch Q) C) Other: C) Va ina ring 1 C3-C3 er: 1 3 (356) recs) (3) c5) 2 (ENE) 0 Don?t know (3 C) Don?t know (3) G) (E) (3 . 0 Natural Estrogen .. . @(53 0 Natural Progestin . all jj-. Dally 0 LESS tha? Testosterone C) Currently taking C) Daily C) Health OReplacedwithnon- .. . rescri tion medications ame ofth'e hormone embe Don?t remember. C) ideefects . . . o. (3 News reports Estrogens Estrogen 8: Progestm C) Doctor recommended C) Premarin C) Estrin ?089513115 0 Provera C) Switched type of HRT C) 0 en C) Estra 101 Prempro Prometrium . C) Not needed C) Es ace C) Menest C) Premphase C) Natural Progestin Hysterectomy C.) Vagifem C) Bi-est Other: C) Other: C) Got breast cancer C) Vivelle CD Climera C) Other: C) Other: C) Other$3313 The next set of questions asks you about your alcohol consumption in the past year and then asks you to think back about your alcohol consumption during different time periods in your life. It you did not drink during the time period OR are not that age yet, fill in ?Do/Did Not Drink.? 37. For each time period, please give us your best guess of how often you drank each type of alcohol .3.- and how many drinks you had each time. Even if the amount you drank changed during the time period, please just estimate your AVERAGE alcohol use during the time period. .zm. - About how many times a week doldid you drink and about. how many drinks each time? Jaw ((47.52: 37A. PAST YEAR A. TIMES PER WEEK B. DRINKS EACH TIME Champagnedeanwm?373. HIGH SCHOOL A. TIMES PER WEEK B. DRINKS EACH C) Did Not Drink .. 5111i. :3 2.1 f. Beer"? .. Red In . Wtewmeor .. . <9 .93. . 9 9 9 9 shot of liquor.? I I B. DRINKS EACH TIME if 37C. AGES 18 - 21 A. TIMES PER WEEK I .- C) Did Not Dunk Beer?ifshot of liquor. ??e-munznu -- 37D. AGES 22 - 39 A. TIMES PER WEEK B. DRINKS EACH TIME . . .-. . -- -. ?Whit?WinW .. cocktail 5r ghaa1:q??r. .uwwmr 37E. AGES 40 - 49 A. TIMES PER WEEK . . ?RedWinef4Ome .Q . . C3 "White Wine Shot Of E) Q) I (E) (E) 37F. AGES 50 A. TIMES PER WEEK 31?; B. DRINKS EACH TIME 0 Did Not Drink {Ethan 1 -- ?es? - 12 oz. Wine 4 oz "was Wine or Christmas@283 a: 95M a may; a a see 1 or. Following are questions about your physical activity at various times in your life. For each of the ages below, please estimate the average amount of time each week and the average number of months each year that you spent in these activities. . 38. STRENUOUS EXERCISE How often did you participate in STRENUOUS exercise activities or sports swimming laps, aerobics, calisthenics, running, jogging, basketball, cycling on hills, racquetball)? AVERAGE HOURS PER WEEK AVERAGE MONTHS PER YEAR I -- 39hr: - ahr's: Lh'ts" r-hr'si-i hrs-I; rearsDuring High .. .. Ages .18 5139121.. .10 . .Q. 0 ""B'em'een Ages 22and39 .. . .. . . HIP-ast Year ofoofofo 0?0 0 oo "o igo ofoifojfofog-?e :ofoioffo j'Qo oi'of'gofofo 39. MODERATE EXERCISE . How often did you participate in MODERATE exercise activities or sports brisk walking, golf, volleyball, cycling on level streets, recreational tennis, or softball)? AVERAGE HOURS PER WEEK -- 1 1 112 7-10 'hr 'hrs hrs- C) AVERAGE MONTHS PERYEAR 1-3 - 7-9" 10-12 None. C) I 0 During High School Bee/veer? Assisil??nd?l Firemen .. . Past Year I ofoo 1152 11 40. How does the amount of exercise you get now compare with how much you got 5 years ago? Moderate exercise: C) Get more now Get about the same now Get less now Strenuous exercise: C) Get more now C) Get about the same now Get less now SMOKING 41. Have you smoked at least 100 cigarettes in 42. 43. your entire life? NO - Skip current smoker 0 YES - I am a former smoker How old were you when you first smoked regularly, and how old were you when you last smoked regularly? C) Never smoked regularly Skip to Q44 Current smoker On average, about how many cigarettes per day do youldid you smoke when you smoked regularly? (1 pack 20 cigarettes) 0 Less than 1 cigarette C) 1?4 0 5?9 C) 10-19 0 20-29 C) 30-39 C) 40+ SECOND-HAND SMOKING (not your own smoking) that you: AND regularly inside your workplace. 44. Please estimate the total number of years a) lived with someone other than yourself who smoked regularly inside your home b) worked with someone who smoked None, skip Seldom/ Never C) A little C) Sometimes 1 C) About half time (40-60%) organic food? C) Less than 1 year C) to 3 years (3 3 to 5 years 0 5 to 10 ears 10 to 2 years . $53 . From Birth c3@ c3@ C913 @363 onORGANIC FOOD 45. Over the past year, on average, how often do you eat organic foods? (include fruits, vegetables, meats, grains, dairy, cheese) C) Most of the food I eat is organic (70~80% C) Almost all the food I eat is organic (90?1 46. For how long have you eaten this amount of More than 20 years goo?Cdbiwg] mm. or. re. STRESS 47. 48. 49. 50. 51. 52. Please rank your stress level during the past year on a scale from 1 to 10 with 1 being very low stress and 10 being very high stress. very low very high What was the major source of your stress during the past year? C) Never In the last month, how often have you felt that you Were unable to control the important things in your life? 0 Never C) Almost never 0 Sometimes C) Fairly often Very often In the last month, how often have you felt confident about your ability to handle your personal problems? 0 Never Almost never 0 Sometimes C) Fairly often C) Very often In the last month, how often have you felt that things were going your way? Fairly often Very often Never C) Almost never C) Sometlmes In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? C) Fairly often C) Almost never 0 Very often C) Sometimes ENVIRONMENT 53. 54. How many years total have you lived with a pet when it was wearing a flea collar? C) 1?2 years C) 20+ ears 3?5 years Don know C) 6?9 ears CD Never lived with a et 10- 9 years 0 Never used ?ea col ars How many timeslin your life have you personally treated a pet for ?eas or ticks with a shampoo, dip, powder or Spray? C) Never 0 10?20 times C) Once or twice More than 20 times 3-10 times 55. 56. 57. 58. 59. 60. 61. 62. How many years total have you lived with a pet when it was wearing a topical liquid to treat fleas or ticks Frontline, Advantage)? 1-2 years 20+ ears 3?5 years C) Don know 0 6-9 ears 0 Never lived with a et 0 10? 9 years Never used topical ea treatment During your life have you ever lived in a place where you or someone else used moth balls or chemical moth repellent? C) No C) Yes How often have you used moth balls or chemical moth repellent in your life? C) Never C) Less than 5 times C) 5?9 times C) 10?19 times C) More than 20 times Before-the age of five, did you go to a day- care or other childcare with at least four other children that were not siblings (or other children with whom you did not live)? C) No C) Don?t know CD Yes Before the age of five, did you ever attend a preschool (school before kindergarten?) C) No C) Don?t know C) Yes Did you ever live within a half-mile of stables or pens where horses, cows, pigs or other hoofed animals were kept? No - Skip to Q62 Yes Don?t know At what ages did you live in such a place? (Choose all that apply:) C) 0-4 20-49 5?9 50?69 C) 10?19 C) 70+ If you had your first child after age 30 or did not have children, why did you have children later or not have children? SOCIOECONOMIC STATUS Socioeconomic status, meaning factors related to such things as occupation, income, and education, is associated with breast cancer risk. The next set of questions wiil help us to better understand why socioeconomic status is associated with breast cancer risk. 63. What is the highest education level obtained by you and your family members? (Please pick only one response for each person) 0000000000 ?64, 0000000000 0000000000 Less than high school . Hi school graduate GED Tec ical school graduate Some college but no degree Associate?s degree Bachelor?s degree Master?s de ee Professiona school degree DDS, DVM, JD) Doctoral de ee Ed. Not applica le 64. What is your usual occupation, that is, the most typical or longest held job that best describes the kind of work you do/did? 65. Please choose the category that best describes the usual occupation of you and your family members. 0 ?21? a? aqisQ?s ?66? ?59a <2?led" 9e? $0 C) C) C) Business C) C) Financial C) C) C) Computer and mathematical C) C) C) Life, physical and social science C) C) C) Lceiga C) C) C) ucation, trainin and library C) C) Arts design, enter ainment, sports and media C) C.) C) Health care ractitioner C) C) Health care echnolo ist C) C) C) Food preparation an serving related C) C) C) Buildm and grounds cleaning and maintenance 0 C) C) Persona care and service C) C) Sales and related 0 C) Office and administrative Stay-at-home parent, unpaid care of others Other: C) C) C) Not applicable Also, please tell us the role of each individual listed: C) C) C) Executive C) C) C) Management 0 C) C) Staff C) C) C) Support . g. .. 1 - oo?oerrem . 1 .. Q-Il'?at-chem .mhmm-mw 66. Are you currently: (please pick only one) 72. How would you describe your current social C) Working in usual occupation daSS? (Please PER one) . C) Working in another occupation Lower (D Upper C) Retired 0 Lower middle Upper C) Not working ut not retired) C) Middle C) Not working looking for work) 73. Did you have enough money to pay your bills 67. Is your current or most recent @8611 month in the last Year? spouse/domestic partner: C) Alwa Sometimes C) Usua Never C) Do not have spouse/ domestic partner C) Working usual occupation 0 Working In another occupatlon 74. If you lost your current source of household 8 git?rg?irkm income, how long could you continue to live C) Don?t know8 at your current address and standard of living? 68. What is your household?s current gross C) 52 months 0 1-5 years annual income? (Total income, from all 8 8 1543;931:1335 Years sources, before taxes) Less than $24,999 75. How would you describe your household?s 8 :8 social class when you were in high school? C) $75000 to $991999 0 Lower 0 Upper middle 0 $100,000 to $149,999 Lower middle 0 Upper C) $150,000 to $299,999 C) Middle $300,000 to $499,999 C) $500,000 or more {State}; 0 know 76a. In what state were you born? C) Decline to Answer 69. How many people are -- -. - - {(33 su orted this States-leed: CED: . PP . . {During-Highs; income, including 76b. In what state 3 school yourself? did you live . 8 during high (50:09 ee ed - 932.2(5) @2 act) coco .509) 70. Do you currently: (EEG) Own the home you live in (have paid off the GIG) mortgage) C) Pay a mortgage on the home you live in C) Rent the home on live in skip to Q72 QED C) Other skip to 72 CECE) 71. What is the market value of your home? 0 Less than $250,000 @360 @361) C) $250,001 to $500,000 $500,001 to $750,000 $750,001 to $1 000,000 (3 Born 0 $1,000,001 to $1,500,000 we) outSIde (3 $1,500,001 to $2,000,000 U.S. More than $2,000,000 GOG) Don?t know C) Decline to answer . K. w. May-M re" Ww?mmsv .2. 3 . .. ?anew.qu .1 i 77. For how many total years during the past 5 years have you taken any of the following medicines regularly (at least once a week $151,333: was 0 . 'z-years _Aspirin (ex. Anacin, Bufferin, Excedrin) I I I I of Off 0:00 Ibuprofen (ex. Motrin, Advil, I I NaprosyMex-Alovo) . . .. Statins (ex- Lipitor. . Osteoporosis medications (EX: .Eosooiox) do; do 0220faverage, how many servings do you typically eat of the following USUAL NUMBER OF SERVINGS foods? {511555}: ii :12 3-4. 5-6 -- 2 per); a ?oor? oer . per. math?: month? j-0200 0 0 1-9f'D Remember: official serving sizes are small. 0 0' Fruit or fruit juice: serving 1/ 2 cup - s"ii?is?gesbi?s sessgisoz' soololl-Regular (not diet) S-odaz?lican (1252-5Non/Low Fat Dairy: cup milk, yogurt, 1 slice cheese Dairy: 1 cup cow?s milk, yogurt, 1 slice cheese 0 Soy: 1 cup tofu, tempeh, soy beans, soy milk, etc. Nuts: 1/2 cup french fries: 21.12.11). ?ops; Erie's. 3 l; 'j .5 5' Sweets: 1 candy bar, 1 medium cookie, etc. Meats: 1_ slice bologna, ham,.3_ slices-ff; salami, 2-pieces bacon, etcRaw Beef: serving 1/ 4 cup :iM'eat: o4 0 Poultry, Chicken, etc.: serving 1/4 cup 0110;017'0j70 0 ffof 0'00 5:0: 0 Refined grains: 1/ 2 cup cereal, rice, crackers, pasta, lovhiteflour tortilla, 1 slice bread, etc. Whole grains: 1/2 cup cereal, crackers, brown rice, pasta, 1 corn tortilla,.1 slice bread, etc. 0 Multivitamin Centrum, One-a-day, etc":0ij 0 3025 "oroo?o 0- 0 0. 0 10.520 10acid, Bsc'omplex or Stress tabs: I I. 79. How much folate does your 80. Have you ever eaten or drunk RAW 81. Have you ever multivitamin contain? dairy products? (unpasteurized milk, eaten RAW beef None 0 400 unpasteurized cheese, or other (ex. steak tartare)? C) 100 mg Donztinow unpasteurized dairy products?) 200 mg 0 Not applicable 233997 I - - - - - Mark Re?ex? terms by Pearson NOS MM271031-1 321 Printed in U.S.A. x4 - M.- m- Mal-?sumnau?