Socio-demographic information |
Identification: House Number: _______; Village: ___________ |
Gender: 1. Male 2. Female |
Age in years: __________ |
Are you head of the household? (yes/no) |
How many people live in the family? 1. Male: _____ 2. Female: ____3. Total: ______ |
What is the level of your education in school years? ________________ |
Current job |
What is your current job? |
1. Farmer-own land |
2. Flower farm worker (greenhouse, pack-house, sprayer, other) |
3. Other (Office worker, small private business, housewife) |
Work experience |
How long have you been working in this job? |
Pesticide use |
Do you use pesticide at home for pest control? (yes/no) |
Do you use pesticides on your own farm? (if a farmer) (yes/no) |
Do they use/spray pesticides in the flower farm? (if you are working in the flower farm) (yes/no) |
Pesticide-related health problems experienced |
Have you ever felt health problems within 48 h of exposure to pesticides in the last 12 months? |
1. Never 2. Once 3. Several times 4. Not exposed to pesticides |
If you ever had health problem within 48 h of exposure to pesticides, which health symptoms did you experienced? (Tick off all the symptom (s) mentioned by the respondents from the below list) |
1. Headache |
12. Abdominal cramp |
2. Dizziness |
13. Chest tightness |
3. Excessive sweeting |
14. Dyspnea |
4. Salivation |
15. Morning cough |
5. Confusion |
16. Day/night time cough |
6. Weakness |
17. Shortness of breath |
7. Anxiety |
18. Wheezing |
8. Loss of consciousness |
19. Miosis |
9. Bradycardia |
20. Eye tear |
10. Vomiting |
21. Rash on hand |
11. Diarrhea |
22. Skin rash |
Exposure to pesticides |
If you ever had health problem within 48 h of exposure to pesticides, the exposure to pesticides occurred through: |
1. Pesticide application for household pest control |
2. Pesticide application at own farm or working at sprayed farm |
3. While pesticide application or working at sprayed flower farm |
Smoking |
Do you currently smoke cigarette (tobacco) daily? (yes/no) |