Skip Navigation
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

National Institute of Environmental Health Sciences

Use this QR code to view the newest version of this document

Your Environment. Your Health.

Recommendations for Common Data Elements for COVID-19 Studies Including Pediatric Participants

Return to Search Results

Oregon State University Chemical Exposure Disaster Questionnaire

Resource Type:
Survey/Questionnaire
Related Resources:
See list of available resources
Contact:
Diana Rohlman
Availability:
Publicly Available, No Cost
Common Data Elements:
No
Date Published:
09/01/2017
Date Record Updated:
03/02/2022
Description:
The Oregon State University Superfund Research Program and the Pacific Northwest Center for Translational Environmental Health are focused on chemical exposures before, during and after disasters. The Centers developed a broad Disaster Protocol, enabling rapid responses to disasters. In the case of Hurricane Harvey, using the pre-positioned protocol, researchers were able to obtain project-specific human subjects ethical approval and initiate data collection within three weeks of Harvey making landfall in Houston. The questionnaire includes virtual consent and assent, consent to receive individual results from the study, and evaluates informed consent via questions gauging comprehension of study activities and types of data being collected. Modules included in the survey: i) Demographics; ii) Exposure History specific to flooding; iii) Environmental Health; iv) Occupational History, using elements sourced from the Disaster Response Research (DR2) platform. Oregon State University Chemical Exposure Disaster Study Protocol Data Dictionary: https://disasterinfo.nlm.nih.gov/content/files/Oregon%20State%20University%20Chemical%20Exposure%20Disaster%20Data%20Dictionary.xlsx Assent statement template: https://disasterinfo.nlm.nih.gov/content/files/OSU%20Chemical%20Exposure%20Disaster%20Assent%20Template.docx Chemical Exposure Consent Template: https://disasterinfo.nlm.nih.gov/content/files/OSU%20Chemical%20Exposure%20Disaster%20Consent%20Template.docx The associated protocol can be found: https://dr2.nlm.nih.gov/search/?q=24238
Content Adapted From:
ACE Toolkit. General Survey Module G: Emergency Response. https://www.atsdr.cdc.gov/ntsip/ace_toolkit.html Question 22 Question 23b Question 23c Adapted from the NIOSH Deepwater Horizon Roster Form, Gulf Coast Oil Spill Initial Survey. https://www.nrt.org/sites/2/files/ERHMS_Final_060512.pdf (Page 117) Question 23 Question 48-50 Community Assessment for Public Health Emergency Response (CASPER): Appendix B: Question Bank https://www.cdc.gov/disasters/surveillance/pdf/casper_toolkit_version_2_0_508_compliant.pdf Question 24a-d Question 31-32 Question 35 Question 37 ATSDR Exposure Form: https://www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf Question 45-46 WTC Health Registry Hurricane Sandy Survey http://www.nyc.gov/html/doh/wtc/downloads/pdf/registry/wtchr-sandy-survey.pdf Question 24e-f Question 25-30 Question 33-34 Adapted Question 36a-c o Question 42 o Question 44 o Question 49 o Question 51 o Adapted Question 53

Additional Descriptors

  • Administration Mode:
  • In-Person Interview, Online or Mobile App
  • Administration Time:
  • 1-15
  • Language:
  • English
  • Number of Survey Questions :
  • 51-74
  • Resource Type:
  • Survey/Questionnaire
  • Study Population:
  • Age
    • Age: Adult Child
      • Children: Adolescent or Teen
  • Event Type:
  • Chemical, Contamination or Release Event
  • Exposure Agent:
  • Chemical Agent

Related Resources

Consent Form
OSU Chemical Exposure Disaster Assent Template
OSU Chemical Exposure Disaster Consent Template

Data Dictionary
Oregon State University Chemical Exposure Disaster Study Protocol Data Dictionary

Last Reviewed: March 06, 2026