CHICAGO Trial
HOME VISIT ASTHMA EDUCATION PROTOCOL
The CHICAGO Trial 6-month intervention for children is delivered in five visits over the course
of 6 months, after a child has been discharged from the Emergency Department (ED) for an
asthma exacerbation. The home visits occur at the following intervals post ED discharge: 2-3
days, 2-weeks, 1 month, 3 months, and 6 months. The purpose of this guide is to provide a
consistent format for Community Health Workers (CHWs) to complete the asthma education
portion of each of these home visits. This education session should take place after all data
collection has been completed by the Research Assistant. The CHW should keep in mind any
key information learned while collecting data in order to appropriately assess self-management
needs, tailor educational messages and address caregiver concerns.
The educational portion of the home visit can usually be delivered in 30 to 60 minutes,
depending on the learning needs of the family and the amount of participation and discussion
among the parent(s) and/or caregiver(s). The CHW should be aware that depending on the
family’s learning needs and/or other issues, all topics in this guide may not be discussed in the
order recommended. The CHW should use judgment to determine how much to include per
session, based on the understanding and attention of the caregiver, and should cover the most
important topics first.
Please note that some items on the the list of supplies for each home visit may not be needed for
a particular visit. Please use your discretion to adapt each list to fit your program’s needs and
capacity.
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
BASELINE VISIT (1ST VISIT, 2-3 DAYS POST ED DISCHARGE)
Visit Objectives:
1. The focus of this visit is on developing a relationship with the family, explaining
intervention goals and purpose, discussing expectations, determining the family’s learning
ability, gauging their existing knowledge and addressing possible social service needs.
2. By the end of this visit, the CHW should have at least discussed: (1) what asthma is and its
pathophysiology; (2) what it means to have asthma “under control”; (3) how to recognize
and respond to asthma symptoms/episodes; (4) medications, their purpose and proper use
and observed medication use techniques.
ASTHMA EDUCATION SESSION
By the end of this visit the caregiver should:
1. Understand what to expect from the CHICAGO Trial Program and the role of the CHW and
their own role as caregiver.
2. Understand what asthma is.
3. Understand what is happening in their child’s lungs when they are having an asthma attack.
4. Understand what it means to have asthma “under control.”
5. Understand the importance of asthma medications and how to use them appropriately.
6. Know how to communicate with their school about their child’s health and how to implement a
504 Plan.
 Supplies:

Home Visit Data Tools

Inhaler checklists (CHW to collect)
A. Assess pt baseline inhaler technique –using standardized
checklist
B. Provide demonstration with verbal instruction
C. Re-assess the teachback –using standardized checklist
D. Repeat as needed up to 3 rounds
I. 2nd round teaching if any step is missed (no mastery)
II. 3rd round teaching if too many steps missed (misuse
present)
III. If misuse still present after 3rd round need reporting
mechanism for feedback to provider/study personnel
E. Review patient handout of instructions—written with picture
images of steps
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

CHW Asthma Education Manual

Program brochure, if available

Behavior Change Plan worksheet

Lung models and lung pictures

CHW Demonstration Device Kit

New spacers/holding chambers

Asthma-related educational handouts (CHW to choose from the library of
handouts based on what is relevant for the family):

5 Things to Know About Asthma

Asthma and Exercise for Children

Asthma First Aid (CAC handout)

Smoking Cessation Handouts
A. Cigarette Diagram
B. RHA Smoking Cessation materials
C. Quitline information

Medication tracking sheet for when device does not have a counter (e.g.,
ProAir, Proventil, Qvar, etc.)

Medication and device instructions and/or cleaning instructions as
appropriate (e.g., MDI, DPI, Nebulizer)

Trigger related educational materials
o
Avoiding pet allergen (provide if allergic)
o
Avoiding cockroach and rodent allergen
o
Avoiding pollen allergen
o
Avoiding dust mite allergen (provide if allergic)
o
Avoiding mold allergen
 Lead Paint and Children

RHA Asthma handouts

504 Plan Brochure (if child is school-age)
Assessment Questions (to generate discussion and tailor education)
3
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
Explain to the caregiver that you are a trained asthma educator, that you are not a doctor or
nurse. Explain that you, as a CHW, are there to spend the time that many doctors do not have
to explain what asthma is, to go over medications and also to answer any questions they may
have. Let them know that if there are questions you cannot answer you will find someone who
knows the answer and will follow up with them.
Before education ask the following questions:

What do you already know about asthma?

What more would you like to learn or understand about asthma?

How is your child’s asthma doing? (Do not have to ask if you collected
information from data sheets.)

What concerns you most about your child’s asthma? (Probe to identify
priorities.)

Complete Behavior Change Plan Worksheet

Longer term plan: What are one or two goals that you would like to meet
over the next 6 months for your child by participating in this program? If
the child is old enough they can contribute to these goals.

Short term plan: What steps can you take to meet each of the longerterm goals, starting now? These goals will be built upon each visit in order to
continue towards reaching longer term goals.
During education ask the following questions:
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
How can you tell your child is beginning to have an asthma attack?

Do you know your child’s warning signs/symptoms of an asthma
attack/emergency?

Can you show me how you give your child their medication? If child is old
enough ask them. Can you show me how you take your medication?

How often do you give your child their medication?

How do you feel about the medications prescribed for your child?

Do you think the medications work?

How do you feel about your child having to take medication every day?
Possibly for the rest of their lives? What is your understanding about the
difference between types of asthma medications?

Does your child use a spacer/holding chamber?

Does your child have a 504 Plan in place at school?
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

What do you think causes your child to start having asthma symptoms?
(Probe to identify all those things that the caregiver thinks trigger the child’s
asthma.)
 Asthma Basics Educational Messages:

What is asthma?

A long-term condition that affects the airways of the lungs.

In a person with asthma three things happen to the airways:
1.
2.
3.
Swelling (inflammation)
Thick, sticky mucus
Tightening of the muscle around the airway

A person with asthma may always have a little swelling or mucus.
During asthma attacks there is so much swelling, mucus and tightness
that the person has trouble breathing.

Asthma cannot be cured (you cannot grow out of it), but it can be
controlled.

A person with asthma should be able to do most things that people
without asthma are able to do as long as their asthma is under control.

Asthma does not mean your child cannot play sports or actively play.
Children with asthma should be able to play and be active. This is
because exercise helps for overall health. Indicate that it is important for the
child’s asthma to be CONTROLLED to participate in these physical types of
activities.

What does good control actually mean? Good control means that your
child:
A. does not have or has minimal day or nighttime symptoms,
B. can participate in all activities,
C. has no emergency department (ED) visits or hospitalizations,
D. hardly or never needs to use their quick relief medication,
E. and never misses school due to asthma.

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What are asthma symptoms?

A symptom is a sign or clue that something is happening or about to
happen.

There are a number of different asthma symptoms and they can be
different for different people.
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

The most common asthma symptoms are:
A. Cough
B. Chest tightness
C. Wheezing (a whistling or rattling sound in your chest)
D. Shortness of breath

It is important to know your child’s asthma symptoms and look out for
them every day since they can be early warning signs that your child may
be having trouble with their asthma.

The earlier you recognize your child’s warning signs and symptoms, the
earlier you can start treatment and possibly avoid going to the ED or your
child being hospitalized.

The following warning signs of an asthma emergency are SERIOUS
and the caregiver should give quick relief medications as instructed on
the child’s Asthma Action Plan (AAP)* and call a medical provider
IMMEDIATELY if:
A. The child is breathing harder than normal while resting.
B. Look at chest and stomach to see if there are something called
‘retractions’. Retractions are when the child is having such a
hard time breathing that the skin sucks in around their collar
bone and around their ribs. You can see the collar bone sticking
out and the skin tightening over the ribs when this happens.
CHW can demonstrate what retractions would look like. For
example, if it is a boy, lift up shirt and have the boy breathe hard
in order to show what the muscles look like. Also, demonstrate
sucking in of neck muscles.
*Call 911 IMMEDIATELY if the quick relief medication does not
work after using as prescribed and/or your child gets worse.
∙
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The following are signs of an EMERGENCY and the caregiver should
call 911 IMMEDIATELY if:
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
A. The child is breathing so hard they cannot walk or talk.
B. The child’s lips or fingernails begin to turn blue.


For either of the above examples the caregiver should follow the child’s
Asthma Action Plan (AAP) (if one is already in place); otherwise they
should call 911 IMMEDIATELY if the quick relief medication does not
work after using as prescribed and/or the child gets worse.
Why are asthma medications important?

It is important to take asthma medications in order to control asthma and
prevent asthma episodes. Note, there are different medications that are
used to prevent attacks, called “controller medications, versus those used
during an attack, called quick relief or “rescue” medications. See below
for further explanation of each type of medication.

Asthma medications work best when they are used as prescribed and
with the correct technique. If they are not used properly or are not given
correctly, the medication will not get into the lungs and your child will
not feel better. Not using medication properly is similar to dropping a
pill on the floor instead of swallowing it. As a result, your child may end
up in the ED or being hospitalized.
There are two types of medications that are used to treat asthma:
a. Quick relief or “rescue” medication – works quickly to open the
breathing tubes/airways and relax the muscle around it. These
medicines should be taken only when needed - when asthma
symptoms occur or during an asthma episode. Sometimes, these
medicines can also be taken before exercise to prevent asthma
symptoms or an attack from occurring while exercising (only
under the advisement of a doctor).
b. Controller medication – works to open the breathing
tubes/airways by preventing and/or reducing the swelling and
mucus inside the breathing tubes/airways. In order for these
medications to work they should be taken every day to control
asthma and prevent more asthma episodes from occurring. These
medicines do not work quickly and they do not provide
immediate relief to asthma symptoms.
If taken correctly, one sign that an attack is beginning or the
asthma is not being controlled is when the rescue medication is
being used more often.
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

Address possible myths or concerns related to medications that
caregivers may have. Key points to remember are:
a. Asthma medications are not addictive.
b. Inhaled corticosteroids (e.g., Flovent, Advair) are not like anabolic
steroids that make athletes big.
c. Inhaled corticosteroids are not likely to affect your child’s height
and growth. These medications focus directly on reducing the
inflammation in the lungs, and do not affect the whole system.

Demonstration of technique used to administer medication and use
devices. Key points:
a. MDIs:
i. Shake all MDIs before use to ensure medicine is uniformly
mixed.
ii. For HFA MDI inhalers the caregiver must remember to
prime (waste doses in air) before starting to use a new
inhaler.
b. DPIs:
i. It is important to hold container properly once medication
is loaded to ensure medicine does not fall out. Indicate to
caregiver that moisture should never enter the DPI
chambers (i.e., during cleaning).
ii. DPIs do not need to be shaken.
iii. Remember: each DPI technique is different! Make sure to
address that child’s particular DPI if one is used.
c. When taking both of these medicines the breath should be held for
10 counts (depends on the age and maturity of child – teach
appropriate method for that particular child).
d. Holding chambers/spacers work better than using the MDI alone
by:
i. Increasing the amount of medicine that reaches the lungs.
ii. Lessening irritation in your child’s throat from the
medicine (i.e., cough, hoarseness, etc.)
iii. Decreasing the chances of yeast infection in the mouth if
using an inhaled steroid.
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
Explain to caregiver how to read and understand the prescription
label, if he/she does not already understand. For ALL medicine stress
the importance of getting refills in a timely manner.
e. Explain to caregiver how to keep track of MDI doses using the
tracking sheet (not necessary to teach tracking sheet for HFA
inhalers with dose counter attached or for inhaled steroids). Key
point(s):
i. Do NOT insert inhaler in water to see if it will float to
determine if medicine is gone.
ii. Do NOT use “shaking” technique to determine if there is
medicine left in the inhaler.
f.
Explain to caregiver how to track doses on dry powder inhalers
(controllers) using counter on the chamber. Key point:
If there is not a way to determine on the chamber when the
inhaler will be empty (Remember each DPI chamber is
different; explain procedure based on the particular DPI
used), explain to the family how to track daily medicine by
dividing the number of doses in the container by the
number of doses used per day.
For example: if a child takes two puffs per day twice a day
for a total of four doses everyday and they have an inhaler
that has 120 doses (120/4=30) in 30 days there will not be
any medicine left. The family should call in a refill or new
prescription before the 30 days is up.
g. For those who use a nebulizer:
i. Stress the importance of NOT washing or rinsing the
nebulizer tubing.
ii. Discuss changing the nebulizer filter.
iii. Discuss how to order additional tubing.
h. Discuss with caregiver how to clean all devices.

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What are triggers? (Briefly discuss – more thorough at next visit)

Triggers are anything that can cause someone with asthma to have an
attack.

Review those triggers the caregiver identified for their child during data
collection and when probed about possible triggers.
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014


If time permits, briefly discuss some avoidance measures for the triggers
identified.
What is a 504 Plan?

A 504 plan is a legal, written document that allows the child with asthma
to:
a. Carry asthma medications during school.
b. Have unlimited access to water and restrooms.
c. Stay indoors on cold weather and/or poor air quality days.
d. Engage in alternate activities when he/she has asthma symptoms
and cannot participate in gym class.
e. Have school staff eliminate any classroom triggers.

Advise the caregiver on the importance of having a 540 plan in place at
their child’s school, and assist them as needed in contacting school staff to
start the process if they do not already have a plan in place.
 Home Visit Conclusion Actions:

Explain to the caregiver that you would like to do a thorough assessment of
the home to identify possible home triggers in two weeks. Get permission
from the caregiver to set up this appointment and identify a time and date that
is convenient for them. If two weeks isn’t possible, make the appointment as
soon as they are available. Let them know you will call to remind them and
confirm.

Review key topics by asking the caregiver to explain how they would tell
someone what asthma is, or how to use the prescribed medications/devices.

Ask the caregiver if they have any questions and/or concerns.

Complete the Behavior Change Plan worksheet.
 Referrals:
 Identify possible referrals to social service agencies or other support services.
 Identify if the family needs assistance connecting with a health care provider
(e.g., primary care physician, asthma specialist, allergist, mental health provider,
etc.)
 Identify if the family has any health insurance issues.
 Follow-up Activities:
If assistance is needed with finding a health care provider or insurance, speak with the CHW
supervisor regarding how to resolve these issues.
10
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
2-WEEK VISIT (2NDVISIT)
Visit Objectives:
1. The focus of this visit is on completing the Home Environmental Checklist (HEC) and
thoroughly educating the caregiver about possible asthma triggers. See page 23-83 for the
full Home Environmental Manual of Procedures (MOP) and HEC.
2. The CHW should also review and reinforce basic asthma messages given at the baseline
visit and review the Behavior Change Plan.
3. The CHW should review and re-teach spacer and medication technique to ensure proper
use.
4. By the end of this visit, the CHW should have thoroughly discussed possible triggers and
completed any education not done at the baseline visit.
5. CHW should identify any housing related issue and follow the Home Environmental Issue
Protocol for addressing it.
6. If the Behavior Change Plan worksheet was not discussed at the baseline visit, this should
be reviewed and goals should be set for the next CHW visit.
ASTHMA EDUCATION SESSION
By the end of this visit the caregiver should:
1. Understand the many triggers that can cause their child to have an asthma episode.
2. Understand the importance of avoidance measures.
 Supplies:

Home Visit Data Tools

Inhaler Checklists (CHW to collect)

CHW Asthma Education Manual

Home Environmental Checklist (HEC)

Behavior Change Plan worksheet

CHW Demonstration Device Kit

New tubing and/or holding chambers

Green cleaning kit

Extra asthma education related materials (CHW to choose from the library of
handouts based on what is relevant for the family)
 Assessment questions:
Use the Home Environmental Checklist to generate questions and discussion. After completion,
review triggers identified from previous visit and then review medication technique.
11
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

What are some things that you are currently doing to help reduce your child’s
exposure to his/her asthma triggers?

What are some things that you would like to learn to help reduce your child’s
exposure to his/her asthma triggers?

Are there any things that are keeping you from helping your child avoid or
reduce his/her exposure to asthma triggers?

Can you show me how you give your child their medication? If child is old
enough ask them. Can you show me how you take your medication?
 Asthma triggers educational messages:
 One of the most important steps in controlling asthma is to identify and reduce
exposure or completely avoid asthma triggers.
NOTE: Triggers that are bolded below are primary triggers per the CHICAGO
Trial, as they are known to be the most common triggers in the communities
served by the trial. Triggers marked with an * are considered secondary triggers.
 There are many different asthma triggers. Allergic asthma is the most common
form of asthma. Including those you have identified (review those triggers the
caregiver identified from baseline visit or during home assessment), the
following can be triggers for people with asthma who have allergies:
 Cockroaches
 Rodents
 Dust mites*
 Mold*
 Pollen
 Pets

The following are also triggers for anyone who has asthma. Including those
you have identified, other possible triggers are:
 Irritants:
o Tobacco Smoke
o Perfumes
o Cleaning supplies
o Gas stoves, fireplace smoke, barbeque smoke and cooking odors
o Air pollution, car exhaust and gas fumes

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Other triggers:
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
o Weather changes
o Colds, flu and other respiratory issues
o Exercise, stress and emotions
o Acid-reflux
o Medication sensitivity
o Food allergies

NOTE: For all of the education points below on primary and
secondary triggers, refer to the Manual of Procedures for the Home
Environmental Assessment for detailed instructions on addressing
each trigger that may be present in the home (pages 23-83).
PRIMARY TRIGGERS
 If there is evidence of cockroaches in the home, explain the following key points:
o Cockroaches can make asthma worse and trigger an asthma attack if
your child is allergic to them.
o Controlling cockroaches can be difficult, but with patience and
persistence you can get rid of them.
o The use of pesticides (e.g., spray Raid, etc.) for controlling cockroaches
may trigger asthma attacks. Pesticide use has been shown to cause
other health problems. If needed, the preferred method should be to
use roach baits (containerized pesticide) or gels.
o Cockroaches can live for months without food, but only 24 hours
without water. Therefore to get rid of cockroaches remove their
sources of water and food.
o Avoidance measures/actions:

Review cockroach allergen handout with caregiver.
 If there is evidence of rodents in the home, explain the following key points:
o Rodents (mice/rats) can make your child’s asthma worse or trigger an
attack.
o Preventing rodents from entering the home is one of the best ways to
reduce exposure.
o The steps to get rid of rodents are similar to controlling for
cockroaches; you must control their access to food and water.
o Avoidance measures/actions:
13
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014

Review rodent allergen handout with caregiver.
 For those families who identify secondhand smoke as their child’s trigger,
explain the following key points:
o Secondhand smoke can make their child’s asthma worse.
o If the caregiver smokes, identify whether they have thought about
quitting.
o Identify anyone else who smokes in the home and brainstorm with the
caregiver possible avoidance measures.
o Avoidance measures/actions:

Review secondhand smoke handout with caregiver.

Make appropriate referral for smoking cessation as
necessary.

Leave relevant anti-smoking materials/handouts.
SECONDARY TRIGGERS
 For those families who identify dust and/or dust mites as their child’s trigger,
explain the following key points:
o What dust mites are.
o All homes have dust mites and this does not mean a person is not
clean.
o Household dust can contain allergens from dust mites.
o Regular dirt and dust can irritate a child with asthma if breathed in.
o Avoidance measures/actions:

Review dust and dust mite allergen handout with
caregiver.
 If there is evidence of mold in the home, explain the following key points:
o Exposure to mold can make your child’s asthma worse or trigger an
attack.
o Mold can be present indoors and outdoors. Molds indoors are often
found where there is moisture and/or excessive humidity. Outside
mold is often found where there is piled up debris or dead wood/trees
and/or standing water and moisture.
o Identifying and removing sources of excess moisture and/or humidity
can help prevent mold growth in the home.
14
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
o The humidity in the home should be below 50% to prevent the
possibility of mold growth. Therefore, the use of humidifiers in the
home is discouraged.
o Avoidance measures/actions:

Review mold allergen handout with caregiver.
 For those families who identify pets as their child’s trigger, explain the following
key points:
o Pets such as dogs, cats and birds can cause a child to have trouble with
their asthma if they are allergic.
o The animal’s dander (flakes from the hair or skin, as well as substances
in the saliva, feces and urine) is what your child is allergic to.
o Avoidance measures/actions:

Review pet allergen handout with caregiver.
 For all other triggers identified, the CHW should refer to the Manual of
Procedures for the Home Environmental Assessment (pages 23-83), the CHW
Asthma Education Manual and/or appropriate educational handout (if
available) to go over avoidance measures.
 Home Visit Conclusion Actions:
 Explain to the caregiver that you would like to return in two weeks to conduct
another home visit. Get permission from the caregiver to set up this appointment
and identify a time and date that is convenient for them. Let them know you will
call to remind them and confirm.
 Review key topics discussed with caregiver, including all triggers identified for
the child. Review avoidance measures for all identified triggers.
 Ask the caregiver if they have any questions and/or concerns.
 Review inhaler technique feedback
 Complete the Behavior Change Plan worksheet, including any specific goals
related to the child’s asthma that are set during this visit (e.g., give the controller
medication every day as prescribed, trigger avoidance measures, following up
with any referrals).
∙ If any asthma goals made during the baseline visit have been achieved,
give positive feedback.
∙ If they are still working on these goals encourage them to continue.
Identify any barriers that may be preventing them from reaching their
goals and modify their improvement plan if necessary.
15
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
 Referrals:
 Identify possible referrals to social service agencies or other support services.
 Identify if the family needs assistance in connecting with a health care provider
(e.g., primary care physician, asthma specialist, allergist, mental health provider,
etc).
 Identify if the family has any health insurance issues.
 Follow-up Activities:
 If assistance is needed with a health care provider or insurance, speak with the
CHW supervisor as to how to resolve these issues.
 If any complex environmental issues are encountered, inform CHW Supervisor
in order to take next steps towards resolving issue.
16
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
1-MONTH VISIT (3RD VISIT)
Visit Objectives:
1. The focus of this visit is on reviewing and reinforcing basic asthma information, reviewing
medication use and technique, and reviewing any trigger-related follow up items from the
Home Environmental Assessment conducted at the last home visit.
2. The CHW will educate the family on the use of the Asthma Action Plan (AAP).
3. By the end of this visit, the CHW should have reviewed and reinforced correct medication
techniques, taught the proper use of an AAP (if available), developed a Behavior Change
Plan with the family for the next three months and clearly identified any housing or
social/legal needs referrals.
ASTHMA EDUCATION SESSION
By the end of this visit the caregiver should:
1. Understand the importance of an AAP.
2. Understand how to use the AAP.
3. Be able to demonstrate appropriate cleaning/remediation methods for their child’s specific
triggers.
 Supplies:

Home Visit Data Tools

Inhaler Checklist (CHW to collect)

CHW Asthma Education Manual

Behavior Change Plan worksheet

Asthma Action Plan (if completed)

CHW Demonstration Device Kit

New tubing and/or holding chambers

Extra asthma education related materials (CHW to choose from the library of handouts
based on what is relevant for the family)
 Assessment Questions (to generate discussion and tailor education):
 What have you done to meet the goals we made in the Behavior Change Plan at the
last visit?
 Did you have any trouble meeting the goals? (If not, congratulate the caregiver. If yes,
encourage the caregiver to keep trying and brainstorm any barriers that may interfere with
their ability to meet their goals.)
 Have you refilled any prescriptions?
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 Have you identified any triggers other than those we discussed at our last visit?
 What changes have you seen in your child’s asthma since our last visit?
 TRIGGER SPECIFIC QUESTIONS:
o
Examples:

Have you been able to stop smoking?

Have you had any success in getting rid of the cockroaches/rodents?

Have you had any success in reducing your child’s exposure to the mold
we discussed in our last meeting?
 Asthma educational messages:
 Review and reinforce asthma education completed at baseline.
 Review medication use and technique.
 Review and reinforce trigger education completed at 2-week visit.
 Home Visit Conclusion Actions:
 Explain to the caregiver that you would like to return in two months to conduct
another home visit. Get permission from the caregiver to set up this appointment
and identify a time and date that is convenient for them. Let them know you will
call to remind them and confirm.
 Review key topics discussed with caregiver, including all triggers identified for the
child. Review avoidance measures for all identified triggers.
 Ask the caregiver if they have any questions and/or concerns.
 Complete the Behavior Change Plan, including any specific goals related to the
child’s asthma that are set during this visit.
 Feedback on inhaler technique
 Referrals:
 Identify possible referrals to social service agencies or other support services.
 Identify if the family needs assistance in connecting with a health care provider
(e.g., primary care physician, asthma specialist, allergist, mental health provider,
etc).
 Identify if the family has any health insurance issues.
 Follow-up Activities:
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If assistance is needed with finding a health care provider or insurance, speak with the CHW
supervisor regarding how to resolve these issues.
19
CHICAGO Trial Community Health Worker Curriculum
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3-MONTH VISIT (4TH VISIT)
Visit Objectives:
1. The focus of this visit is on teaching cleaning techniques that are effective in reducing
asthma home triggers, and on completing the Home Environmental Checklist (HEC), noting
any negative changes and/or improvements. See page 23-83 for the full Home
Environmental Manual of Procedures (MOP) and HEC.
2. The CHW will review and reinforce asthma education and evaluate caregiver’s success in
reaching goals as outlined in the Behavior Change Plan, modifying and/or creating new
goals as necessary. Trigger avoidance techniques will be reviewed and demonstrated as
appropriate.
3. The CHW should review and re-teach spacer and medication technique to ensure proper
use.
4. The CHW will review the correct use of the Asthma Action Plan (AAP) with the family,
noting any changes in triggers or medication use if appropriate.
5. By the end of this visit, the CHW should have reviewed and demonstrated avoidance
measures for all identified triggers as appropriate, reviewed appropriate use of AAP ,
developed an Behavior Change Plan with the family for the next three months and
identified any housing or social needs referrals.
ASTHMA EDUCATION SESSION
By the end of this visit the caregiver should:
1. Demonstrate appropriate cleaning methods to reduce their child’s triggers.
2. Explain avoidance measures for those non-housing related asthma triggers their child may have.
3. Have all appropriate referrals and resources for any other asthma-related issues.
 Supplies:

Home Visit Data Tools

Inhaler Checklist (CHW to collect)

CHW Asthma Education Manual

Home Environmental Checklist (HEC)

Behavior Change Plan worksheet

Asthma Action Plan
 CHW Demonstration Device Kit
 Caulk and gun (for demonstration only)

20
New tubing and/or holding chambers
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
Extra asthma education related materials (CHW to choose from the library of handouts
based on what is relevant for the family)
 Assessment Questions (to generate discussion and tailor education):
 What have you done to meet the goals we made in the Asthma Improvement Plan at
the last visit?
 If necessary, follow up regarding allergy test results/doctor’s visit. Record results or
help with attending appointment, etc. as needed.
 Did you have any trouble meeting the goals? (If not, congratulate the caregiver. If yes,
encourage the caregiver to keep trying and brainstorm any barriers that may interfere with
their ability to meet their goals.)
 Did the caregiver follow-up on all referrals? Refill any prescriptions?
 Have you identified any triggers other than those we discussed at our last visit?
 What changes have you seen in your child’s asthma since our last visit?
 Asthma educational messages:
 Home cleaning activities to reduce exposure to triggers:

Cleaning your home regularly and thoroughly is an important way to help a
child with asthma stay healthy.
 Home Visit Conclusion Actions:
 Explain to the caregiver that you would like to return in three months to conduct
another home visit. Get permission from the caregiver to set up this appointment
and identify a time and date that is convenient for them. Let them know you will
call to remind them and confirm.
 Review key topics discussed with caregiver, including asthma basics, appropriate
medication use and all triggers identified for the child. Review avoidance measures
for all identified triggers.
 Ask the caregiver if they have any questions and/or concerns.
 Complete the Behavior Change Plan, including any specific goals related to the
child’s asthma that are set during this visit. Modify and/or set new goals as
appropriate.
 Provide feedback on inhaler technique
 Referrals:
 Identify possible referrals to social service agencies or other support services.
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 Identify if the family needs assistance in connecting with a health care provider (e.g.,
primary care physician, asthma specialist, allergist, mental health provider, etc).
 Identify if the family has any health insurance issues.
 Follow-up Activities:
 If assistance is needed with a health care provider or insurance, speak with the CHW
supervisor as to how to resolve these issues.
22
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
6-MONTH VISIT (FINAL VISIT)
Visit Objectives:
1. The focus of this visit is on wrapping up all loose ends, completing the final Home
Environmental Checklist (HEC), and graduating the family out of the program. See page
23-83 for the full Home Environmental Manual of Procedures (MOP) and HEC.
2. The CHW should review and reinforce all education provided over the year.
3. The CHW will go over all goals and review achievements.
4. The CHW will review any new medications and/or environmental problems since the last
visit.
5. The CHW will review the most recent AAP with the family.
6. Any final social service and/or housing needs should be identified and resources and/or
referrals should be given.
7. By the end of this visit, the CHW should have thoroughly reviewed all goals and
accomplishments made and reviewed all asthma education, including specific trigger
avoidance measures.
8. Provide family with a certificate of program completion, as well as a Behavior Change Plan
that they can continue to work on.
ASTHMA EDUCATION SESSION
By the end of this visit the caregiver should:
4. Demonstrate appropriate cleaning methods to reduce their child’s triggers.
5. Explain avoidance measures for those non-housing related asthma triggers their child may have.
6. Have all appropriate referrals and resources for any other asthma-related issues.
 Supplies:

Home Visit Data Tools

CHW Asthma Education Manual

Home Environmental Checklist (HEC)

Behavior Change Plan worksheet

Asthma Action Plan
 CHW Demonstration Device Kit
23

New tubing and/or holding chambers

Green cleaning kit

Extra asthma education related materials (CHW to choose from the library of handouts
based on what is relevant for the family)
CHICAGO Trial Community Health Worker Curriculum
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
Inhaler checklists
 Assessment Questions (to generate discussion and tailor education):
 What have you done to meet the goals we made in the Behavior Change Plan at the
last visit?
 Did you have any trouble meeting the goals? (If not, congratulate the caregiver. If
yes, encourage the caregiver to keep trying and brainstorm any barriers that may
interfere with their ability to meet their goals.)
 Did the caregiver follow-up on all referrals? Refill any prescriptions?
 Have you identified any triggers other than those we discussed at our last visit?
 What changes have you seen in your child’s asthma since our last visit?
 Asthma educational messages:
 Home cleaning activities to reduce exposure to triggers:

Cleaning your home regularly and thoroughly is an important way to help a
child with asthma stay healthy.
 Home Visit Conclusion Actions:
 Review all key topics discussed with caregiver over the past six months, including
asthma basics, appropriate medication use, and all triggers identified for the child.
Review all avoidance measures for identified triggers.
 Ask the caregiver if they have any further questions and/or concerns.
 Give the caregiver their certificate of completion and Behavior Change Plan.
 Give feedback on inhaler technique
 Referrals:
 Identify any additional resources the family may need and make appropriate
referral.
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CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
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CHICAGO Trial
MANUAL OF PROCEDURES
HOME ENVIRONMENTAL ASSESSMENT
This manual outlines the specific procedures to be taken by Community Health Workers
(CHWs) to address asthma triggers found in the home environment during the Home
Environmental Assessment. The Home Environmental Assessment occurs at the following
intervals: 2-week visit, 3-month visit, and 6-month visit. The primary focus of the manual is on
procedures for addressing cockroaches, rodents, and tobacco smoke, with a secondary focus on
mold and dust mites. Procedures for addressing additional triggers, both allergens and
irritants, are discussed in the Appendix.
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
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CHICAGO Trial
MANUAL OF PROCEDURES
HOME ENVIRONMENTAL ASSESSMENT
TABLE OF CONTENTS:
General Protocol and Procedures………………………….............................. 25
Trigger Education Protocol…………………………………………………….27
Background and Procedures for Addressing Triggers……………………...31
Primary Triggers
Cockroaches and Rodents……….………………………………….31
Tobacco Smoke……………………………...……………………....37
Secondary Triggers
Mold/Mildew……………..………………………………………....38
Dust Mites…………………… ……………………………………..40
Appendix………………………………………………………………………...44
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CHICAGO Trial Community Health Worker Curriculum
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GENERAL PROTOCOL AND PROCEDURES
Objectives:
1. The focus of the Home Environmental Assessment is on completing the Home
Environmental Checklist (HEC) (see Appendix for full questionnaire) and thoroughly
educating the caregiver about possible asthma triggers and steps they can take to avoid
and/or remediate any triggers present in the home.
2. By the end of this assessment, the CHW should have thoroughly discussed possible triggers
and avoidance strategies based on the procedures outlined below for each trigger.
3. CHW should identify any housing related issue and follow the Home Environmental Issue
Protocol for addressing it.
By the end of this visit the caregiver should:
1. Understand the many triggers that can cause their child to have an asthma episode.
2. Identify specific strategies to avoid asthma triggers, both in and outside the home.
3. Understand the importance of trigger avoidance measures.
 Supplies for Home Environmental Assessment visit:

Manual of Procedures for Home Environmental Assessment

Home Environmental Checklist (HEC)

Green cleaning kit

Trigger related educational materials
 Cockroaches and rodents
 Tobacco Smoke
o
Quitline Information
o
RHA Smoking Cessation handouts
 Mold/Mildew
 Dust Mites
 Avoiding pet allergen
 Avoiding pollen allergen
 Green Cleaning Tips/Recipes
 Others?
 Assessment questions:
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CHICAGO Trial Community Health Worker Curriculum
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Use the Home Environmental Checklist to generate questions and discussion.
o
Review triggers identified from previous visit (based on home trigger
assessment/checklist, Appendix Page 28).

Review allergy testing and importance of getting allergy tested to further
identify triggers, if the child has not already been tested.

What are some things that you are currently doing to help reduce your child’s
exposure to his/her asthma triggers?

What are some things that you would like to learn to help reduce your child’s
exposure to his/her asthma triggers?

Are there any things that are keeping you from helping your child avoid or
reduce his/her exposure to asthma triggers?
 Asthma triggers educational messages:
 One of the most important steps in controlling asthma is to identify and reduce
exposure or completely avoid asthma triggers.
 There are many different asthma triggers. Allergic asthma is the most common
form of asthma. Including those you have identified (review those triggers the
caregiver identified from baseline visit or during home assessment), the
following can be triggers for people with asthma who have allergies:
 Cockroaches
 Rodents
 Mold
 Dust Mites
 Pets
 Pollen

The following are also triggers for anyone who has asthma. Including those
you have identified, other possible triggers are:
 Irritants:
o Tobacco Smoke
o Perfumes
o Cleaning supplies
o Gas stoves, fireplace smoke, barbeque smoke and cooking odors
o Air pollution, car exhaust and gas fumes
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
Other triggers:
o Weather changes
o Colds, flu and other respiratory issues
o Exercise, stress and emotions
o Acid-reflux
o Medication sensitivity
o Food allergies
As mentioned in the introduction, procedures for addressing the bolded triggers will be
the main focus of this manual. Procedures for addressing all other listed triggers can be
found in the Appendix, beginning on page 45.
TRIGGER EDUCATION PROTOCOL
For each identified trigger, educate the family on why and how each can be a trigger using the
key educational points listed under each trigger below. Refer to the indicated pages for a full
explanation of addressing each trigger.
PRIMARY TRIGGERS
 COCKROACHES
 Look for evidence of cockroaches in the home, such as:
29

Droppings – roach droppings are small and black and often look like
grains of ground pepper

Egg casings – cockroach eggs look like a bean, are usually a brownish red
color, and are about 2 millimeters in length and 1 millimeter in width.
They are left behind when a cockroach has recently hatched.
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
Odor – cockroaches give off a strong, very oily odor, which becomes
extremely pungent when large numbers of roaches are present

Presence of roaches during the day time – roaches are nocturnal insects,
so if they are visible during the day, that is often a sign of a severe
infestation
Note: Putting down sticky traps may help determine if there are roaches present in
the home.
 If there is evidence of cockroaches in the home, explain the following key points*:
o Cockroaches can make asthma worse and trigger an asthma attack if
your child is allergic to them.
o Controlling cockroaches can be difficult, but with patience and
persistence you can get rid of them.
o The use of spray based pesticides (e.g., spray Raid, etc.) for controlling
cockroaches is ineffective and may trigger asthma attacks. Pesticide
use has been shown to cause other health problems. If needed, the
preferred method should be to use roach baits (containerized
pesticide), gels and/or boric acid.
The most effective, sustainable and safe method to combat roach
infestation is via the use of Integrated Pest Management techniques:
o Remove sources of food and water. Cockroaches can live for months
without food, but only 24 hours without water.
o Find where cockroaches are entering from, and close any cracks or
holes with caulk and/or steel wool.
o Do not leave food out on the counters or above the fridge. Store food
in storage containers.
o Avoidance measures/actions:

Review cockroaches and rodent handout with caregiver.
*For more information and for a full list of procedures for addressing cockroaches, refer to
pages 31-37 of this manual.
 RODENTS (Mice, Rats)
 Look for evidence of rodents in the home, such as:
o Droppings
30
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Mouse
Droppings
Rat
Droppings
o
Urine odors – both mice and rats urinate frequently throughout the
day, thus leaving an odor in the areas they frequent
o
Sounds – mice and rats produce squeaking, gnawing, scratching and
digging noises that can be heard, especially at night time
 If there is evidence of rodents in the home, explain the following key points*:
o Rodents (mice/rats) can make your child’s asthma worse or trigger an
attack.
o Preventing rodents from entering the home is one of the best ways to
reduce exposure.
o The steps to get rid of rodents are similar to controlling for
cockroaches; you must control their access to food and water.
o Avoidance measures/actions:

Review rodent allergen handout with caregiver.
*For more information and for a full list of procedures for addressing rodents, refer to pages
31-37 of this manual.
 TOBACCO SMOKE
 For those families who identify secondhand smoke as their child’s trigger,
explain the following key points*:
o Secondhand smoke can make their child’s asthma worse.
o If the caregiver smokes, identify whether they have thought about
quitting.
o Identify anyone else who smokes in the home and brainstorm with the
caregiver possible avoidance measures.
o Avoidance measures/actions:

31
Review secondhand smoke handout with caregiver.
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
Make appropriate referral for smoking cessation as
necessary.

Leave relevant anti-smoking materials/handouts.
*For more information and for a full list of procedures for addressing exposure to tobacco
smoke, refer to page 37-38 of this manual.
SECONDARY TRIGGERS
 MOLD/MILDEW
 If there is evidence of mold in the home, explain the following key points*:
o Exposure to mold can make your child’s asthma worse or trigger an
attack.
o Mold can be present indoors and outdoors. Indoor mold is often found
where there is moisture and/or excessive humidity. Outside mold is
often found where there is piled up debris or dead wood/trees and/or
standing water and moisture.
o Identifying and removing sources of excess moisture and/or humidity
can help prevent mold growth in the home.
o The humidity in the home should be below 50% to prevent the
possibility of mold growth. Therefore, the use of humidifiers in the
home is discouraged.
o Avoidance measures/actions:

Review mold allergen handout with caregiver.
* For more information and for a full list of procedures for addressing mold/mildew, refer to
page 38-40 of this manual.
 DUST MITES
 For those families who identify dust and/or dust mites as their child’s trigger,
explain the following key points*:
o What dust mites are.
o All homes have dust mites and this does not mean a person is not
clean.
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o Household dust can contain allergens from dust mites.
o Regular dirt and dust can irritate a child with asthma if breathed in.
o Avoid use of humidifiers.
o Maintain household humidity below 50%.
o Avoidance measures/actions:

Review dust mite allergen handout with caregiver.
*For more information and for a full list of procedures for addressing dust mites, refer to
pages 41-44.
33
CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
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BACKGROUND AND PROCEDURES FOR ADDRESSING TRIGGERS
PRIMARY TRIGGERS

COCKROACHES AND RODENTS
Please note (for CHW):
Cockroaches and rodents such as mice and rats can be embarrassing and bothersome
pests to have. For many, there may be shame associated with having such pests. Care should
be taken when bringing up the issue of having pests as some individuals and families may
not feel comfortable discussing this issue. If an individual or family does not bring up having
pests on their own, you could begin the discussion by going down the list of possible asthma
triggers and mentioning that many people do not recognize that pests can trigger asthma
episodes. Cockroaches, mice, and rats may trigger asthma episodes if a person is allergic to
them.
Background:
In cockroaches, allergens can be found in the whole body of the cockroach, its feces, egg
casings, and cast skin fractions.
Roach droppings/feces
34
Roach egg shell casings
Roach shedding skin
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Allergens can also be found in their regurgitated digestive juices – a brownish stain that is
often mistaken for cooking grease.
In mice and rats, allergens can be found in the rodent’s hair, skin flakes, urine and saliva.
When allergens for both of these pests become a part of the household dust a person can
inhale them and have an allergic reaction that may then trigger them to have an asthma
episode.
Pests such as cockroaches thrive in environments where there is easy access to food,
water, and warmth (shelter). They are often found in cracks and crevices one quarter inch
thick or smaller (similar to the thickness of a dime). Cockroaches can eat almost anything.
They will eat food crumbs, grease, trash, cardboard glue, and whatever else is available.
They will drink water found in sinks, around counters, on floors, in pet bowls, showers,
sweaty pipes, refrigerator drip pans and gaskets, and the AC unit. Cockroaches are most
visible in a home during the night. If cockroaches are regularly seen during the day, this may
indicate that a home is heavily infested.
Mice and rats thrive in warm environments where there is easy access to food and
water. Once in the home there are several measures that must be taken to rid the home of
these pests.
Procedures for addressing cockroaches and rodents:
As mentioned in the protocol above, it is first important to thoroughly look for signs of
cockroaches and rodents, including droppings, egg shell casings, odors and sounds (see
pages 5-6 above for review of what to look for).
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CHICAGO Trial Community Health Worker Curriculum
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In all the measures listed below, avoidance of pesticides is the preferred method. Some
pesticides such as aerosols sprays and bombs for roaches and/or mice may trigger an asthma
episode and should therefore be avoided.
The measures below follow Integrated Pest Management (IPM) strategies which suggest the
following measures for pest control:
1. Keep pests out.
2. Remove pests’ food and water.
3. Reduce pests’ shelter.
4. Monitor for pests.
5. Treat existing pest problems.
 Measures that can be taken to limit exposure to pests are:
o
Keep pests out by removing their ability to enter the home. Look for holes or cracks
where pests can enter the home. Look for evidence of pests (e.g., their feces, chewed
up food boxes, etc.)
o
Remove items delivered in cardboard boxes as cockroaches love to enter a
home through cardboard boxes.
o
For doors with a quarter inch or more space beneath them, door sweeps
should be installed to prevent pests from walking into the home. Also
families should avoid propping doors open.
o
For cracks and holes in the wall or cabinets, caulk should be used to seal
them up. If it is a large hole, steel wool (for mice problems) or boric acid (for
36
CHICAGO Trial Community Health Worker Curriculum
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© 2014
cockroach problems) can be put into the hole or crack before sealing up with
caulk. When sealing cracks or holes, special attention should be paid to gaps
around pipes, ducts, baseboards, and window frames.
o
Remove pests’ food and water. As long as pests have food and water they will
continue to thrive and multiply.
o
Clean thoroughly, paying special attention to clean behind the stove and
refrigerator and other areas not cleaned regularly. Also vacuum and clean
those areas where food is eaten and crumbs may be left behind.
o
o
Eat only in one place, preferably in the kitchen.
o
Put food away as soon as the family has finished eating.
o
Remove garbage daily.
o
Store food in clear plastic or other pest-proof containers.
o
Repair leaking or dripping faucets and other leaks.
Treat existing pest problems by provide the family with bait stations, and/or boric
acid for roaches, and glue or wooden traps for mice. Follow instructions below for
use.
o
Roach specific measures
o
Bait Stations for roaches:
 Place bait stations in areas where cockroaches have been seen and
where they hide (e.g., under the sink, in the pantry or cupboard,
behind appliances and/or toilets).
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 Use 4-6 bait stations per 100 sq ft. In most cases, a minimum of 12 bait
stations should be used at one time, placing 10 baits in the kitchen and
two in the bathroom. If cockroaches are seen in other areas such as
bedrooms or utility rooms, use 2-4 additional baits.
 Substantial reductions in cockroach numbers should occur within 1-3
weeks of treatment.
 Repeat the procedure after 2 weeks time.
o
Boric Acid for roaches:
 Shake the bottle well.
 Twist open the cap.
 Apply powder in a thin layer to the target area: under and behind
refrigerator, stove, sink, dishwasher, washing machine and dryer,
water pipes, cracks and crevices along baseboards and corners of
cabinets, cupboards and closets. It is very important that the boric
acid is not applied in a heavy layer, as cockroaches will avoid piles or
accumulations.
 Roaches will eat the powder, travel back to their nest, and eventually
die. Cockroaches eat each other, and when one cockroach eats another
cockroach that has consumed boric acid, they will die as well.
 Re-apply powder as necessary.
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 Boric acid can also be used in conjunction with other cockroach control
products, such as the bait traps.
 WARNING: Never apply boric acid onto countertops or other exposed
surfaces, especially those used to prepare food.
o
Mouse specific measures:
 Glue traps:
o
Peel off paper on the back side of the glue trap.
o
Place the trap against the wall in areas where mice have been
observed.
o
After use, dispose of the trap.
 Wooden mice traps:
o
Place bait such as cheese, salami, bacon or peanut butter on
the bait holder on the trap.
o
Set the trap according to instructions.
o
Place the trap as near to the wall as possible with the bait
facing the wall.

TOBACCO SMOKE
Tobacco is the most important irritant and is a major cause of asthma symptoms for
anyone with asthma. If a caregiver smokes in the home or car, the smell can linger in carpets,
draperies, furniture and the air. If a parent smokes it is better for their child if they can stop
smoking.
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Procedures for addressing tobacco smoke:

Suggest that the family not allow smoking in the home or car.

If they can smoke outside, help to create a plan to make this work throughout
the year. For example, suggest that the caregiver or family member who smokes
leave a “smoking jacket” by the door that they put on before the go out to smoke
and take off again before going back in the home. Assist them in picking a
designated smoking spot outside, preferably one that is protected so that it is
more comfortable in winter months. Advise that all ashtrays are left outside.

Make a referral to the Illinois Tobacco Quitline for phone smoking cessation
services, and/or available in-person smoking cessation classes for smoking
cessation services.

If they cannot or are unwilling to stop smoking at the current time, suggest to
not smoke around the child or adult with asthma. If they can, it is preferred if
they smoke outside and wear a jacket that they can remove upon returning
inside the home. For all other irritants the best way to limit the person’s
exposure would be to avoid them if they can.
SECONDARY TRIGGERS

MOLD/MILDEW
Background
Molds are a natural part of the environment. Molds grow outdoors and indoors.
Outdoors, molds play an important part in nature by breaking down dead organic matter
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such as fallen leaves and dead trees, but indoors, mold growth can be a problem. Molds
reproduce by means of spores; the spores are invisible to the naked eye and float through the
outdoor and indoor air.
Outdoors, mold can be found in places such as those with fallen leaves, bark of trees,
garden debris, stacked wood, dense forest, standing water and areas of poor drainage.
Indoors mold may begin growing when the mold spores land on surfaces that are damp or
wet. Molds cause damage inside the home because molds digest organic material,
eventually destroying the material they grow on.
Mold also has the potential to cause health problems. Molds produce allergens and
irritants and in some cases potentially toxic substances. Inhaling or touching mold or mold
spores may cause an allergic reaction in sensitive people and lead to sneezing, red eyes, skin
rashes, and/or asthma attacks.
It is important to look for moisture in the home because mold needs water in order to
grow. Molds may often be found indoors in areas where there is excess moisture such as
kitchens, bathrooms, and basements. Condensation found on windows and walls is also a
sign of high moisture levels in the home. In addition, there is the potential for mold growth
in any of the following situations:
41
o
Water damage due to flooding,
o
Sewage back-up from flooding in the area,
o
Plumbing or roof leaks,
o
Damp basements or crawl spaces,
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o
Overflows from sinks or bathtubs, or
o
High humidity (i.e. steam cooking, dryer vents, humidifiers).
Mildew and mold will develop within 24 to 48 hours of water exposure. It will continue
to grow until steps are taken to eliminate the source of moisture and effectively deal with the
mold problem. The most important way to reduce exposure to mold is to fix the cause of the
mold (e.g., fix leaks, etc.) rather than just clean it up because the mold will most likely grow
back.
Procedures for addressing mold:
 Measures that can be taken to limit exposure to mold are:
o
Dry damp or wet items within 24 to 48 hours to avoid mold growth.
o
Fix water leaks (such as leaky plumbing) as soon as possible.
o
Avoid the use of humidifiers.
o
Keep humidity in the home below 50%. Indoor humidity can be monitored with the
use of a humidity gauge. If the humidity in the home rises above 50%, reduce the
moisture in the home with dehumidifiers, fans, and air conditioners.
o
Open a window or turn on an exhaust fan when there is excessive moisture in a
room, such as when showering or cooking.
o
Regularly clean tubs, sinks, and other places where mold or mildew may grow.
o
If mold is found, clean using Green Cleaning methods (see tip sheets) and dry
completely.
o
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Replace mold damaged materials such as ceiling tiles and carpet.
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o
When outdoor mold counts are high, keep the windows and doors of the house
closed and keep the air conditioning on. This helps to keep mold spores from
entering the home.
o
Avoid places outside where molds are likely to be found (e.g.., woody areas where
there are fallen leaves, garden debris or standing water). If these areas cannot be
avoided, it is suggested that a well-fitted mask and goggles be used to avoid
exposure.
o Don’t hang clothes outside, where they can become landing areas for mold spores.

DUST MITES
Background
Dust mites are microscopic organisms that are present in most households regardless of
cleanliness. To survive, dust mites need food and humidity. The dust mite diet consists of dead
human skin (skin scales) and absorbing humidity from the atmosphere. Therefore, dust mites
thrive in environments where the humidity is high (an indoor humidity above 50%) and where
there is plenty of food for them to eat. They are most often found in mattresses and bedding,
sofas, carpets, stuffed animals or any woven material (draperies and curtains).
The parts of the dust mite that people are allergic to are their dead body parts and their
fecal pellets. When they die these become integrated into the regular household dust. When a
person breathes in these allergens and they are allergic to them, they may have an allergic
reaction. This allergic reaction may then trigger a person to have an asthma episode.
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Even if a child or adult is not allergic to dust mites, breathing in large amounts of dust
and dirt may also irritate the sensitive airways of the lungs of someone with asthma The
avoidance measures listed below can therefore be useful to all persons with asthma, not only
those with a dust mite allergy.
Procedures for addressing dust mites
 Measures that may help limit exposure to dust/dust mites are:
o
Keep humidity in the home below 50%. Dust mites thrive when the indoor humidity
is higher than 50-60%. Humidity in the home can be measured using a humidity
gauge.
o
Opening windows and using air conditioners when the humidity is high can
decrease humidity in the home and reduce the number of mites. The use of a
dehumidifier is also an option for those who are able to invest in one or have one
available.
o
Avoiding the use of humidifiers in the home.
o
Removing carpets (especially from bedroom) and using hardwood or vinyl flooring
instead. If removal is not possible:
44
o
Vacuum carpets, area rugs, and floors regularly. Use of a HEPA filter
vacuum or vacuum bag is recommended.
o
Mop hard surface floors regularly.
o
Wash throw rugs regularly in hot water (130°F or higher).
o
Clean baseboards regularly using a damp cloth with warm soapy water.
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o
Removing upholstered furniture. If this is not possible:
o
Cover upholstered furniture with washable slipcovers or sheets and wash in
hot water weekly.
o
Vacuum upholstered furniture regularly, including removing cushions and
vacuuming in cracks and crevices.
o
Avoid having the person with asthma sleep on upholstered furniture.
o
Minimize clutter that can accumulate dust.
o
Remove all stuffed animals from an allergic child’s bed and sleeping area. If not
possible:
o
Limit the number of stuffed toys on the child’s bed and sleeping area to those
few that can be washed in hot water.
o
If washing the stuffed animals is not possible or difficult, these soft toys can
be placed in plastic bags, sealed and placed in a freezer for 24 hours once a
week. This will kill the dust mites, however to remove the allergen the toys
must be vacuumed before returning to the child.
o
Removing bookcases and shelving that collect dust from the person’s room. If not
possible:
o
Use a damp cloth for dusting, so that dust particles are trapped, rather than
moved about.
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o
NOTE: all dusting should be done when the person with asthma is not
around. If the person is responsible for this cleaning, they should wear a dust
mask to prevent exposure.
o
If a family is against removing stuffed animals and books from a child’s room, an
alternative may be placing the child’s favorite toys and/or books in a plastic
container.
o
Allergy/dust proof mattress and pillow covers can be purchased at stores such as
Target or Walmart. These covers may help to reduce the child’s exposure to dust
mites in children who have a dust mite allergen, and in turn help decrease
symptoms. However, it is important to note that the covers are not guaranteed to
have a direct effect on symptoms.
o
Washing all bedding in hot water (130°F or higher) weekly. If bedding is covered in
allergy/dust-proof covers these should be washed as well according to the
manufacturer’s instructions. If this is not possible, drying all bedding at a very high
temperature (130°F or higher) for at least 30 minutes may help. However this
method is not as effective as washing in very hot water and drying.
o
Remove all soft curtains and window treatments and use blinds instead. If this is not
possible, wash all window treatments in hot water (130°F or higher) regularly.
PLEAST NOTE: Once a trigger such as roaches, dust mites and/or mold is successfully
removed or controlled, the child’s symptoms can generally expect to decrease after a period
of 4-6 months.
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
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© 2014
APPENDIX
Other Triggers
As discussed earlier, in addition to the allergic triggers listed above, there are many other nonallergenic triggers including environmental irritants that can cause a person to have an asthma
episode.
Some other triggers are exercise, colds and/or flu, etc. Listed below are some avoidance
measures for these.
Allergens:

PETS. All warm-blooded animals such as dogs, cats, birds, and other furry pets
produce substances called allergens that can trigger asthma in people who have
asthma and are allergic to these animals.
Animal allergens include dander – the skin flakes from the hair or skin of the animal
as well as substances in the saliva, urine and/or feces of animals. It is very sticky and
can stick to walls, furniture, clothing and other surfaces. It can stay in your home for
several months, even after removing the animal. Animal dander may move from one
house to another on a person’s body and may be found in homes where an animal
has never lived. Just because you do not notice any change in symptoms when near
an animal does not mean that you are not allergic to them.
If a child or adult is sensitive or allergic to these allergens, having the animal in the
house may make the person’s asthma worse. Allergy testing by a qualified doctor can
help individuals and families learn if they or their child is allergic to pets. If the
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person with asthma is found to be allergic, the best approach is to remove the pet
from the home. In cases where removing the pet entirely is not an option, below is a
list of specific measures that can be taken to limit exposure to pet allergen:
o
Keep the pet outdoors whenever possible.
o
Do not allow pets in the bedroom of the person with asthma.
o
Thoroughly clean the bedroom to remove any pet dander.
o
If possible, remove all upholstered (cloth-covered) furniture and carpeting,
especially from those rooms where the person with asthma spends the most
time.
o
Wash the pet at least once a week to reduce pet allergen.
o
Wash hands after touching the pet.
o
Use a room air cleaner that has a HEPA filter.
o
Using a vacuum cleaner with a HEPA filter may help remove pet dander
found in the carpet or on upholstered furniture.
 POLLEN. Allergies related to pollen are probably the best known allergy. Pollen
from trees, grasses and weeds may cause allergy symptoms which may then trigger
asthma symptoms. Most people associate pollen allergies with the outdoors.
However, significant levels of pollen can be found in the home. Most pollens are
wind-borne. This means they can blow indoors (typically through open windows and
doors) and trigger allergic symptoms not only outdoors but within your home.
Allergy testing by a qualified doctor can help individuals and families learn if they or
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their child is allergic to pollen. It can also help identify which type of pollen the child
is allergic to and should avoid.
Wind pollinated trees, grasses, and weeds produce pollen during various times of the
year. Below is a list of seasons that the various pollens are at their highest in the
Midwest:
o
Tree pollen – early spring (March – June)
o
Grass pollen – late spring/early summer (May – July)
o
Weed pollen – late summer/fall (August – October)
 Measures that may be taken to limit exposure to pollen are:
o
Avoiding intense outdoor activities, such as exercise or strenuous work
during the early morning and late afternoon hours when pollen counts are
usually their highest. It is important to emphasize that exercise is healthy for
children and adults with asthma; however, if they have pollen allergies, the
individual must take special precautions during their particular pollen
season.
o
Keep doors and windows shut and use the air-conditioning or fans to keep
the house cool. This will limit the amount of pollen that enters the home
through open windows and doors on days when the pollen count is high.
o
Use a clothes dryer rather than hanging laundry outside where it can attract
pollen.
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o
Wash hair and remove outside clothes before going to bed to avoid getting
pollen in your bedding.
 FOOD AND MEDICATION. Many people with asthma report problems with
eating certain types of food (e.g., shrimp or peanuts) or taking certain medicines (e.g.,
aspirin, ibuprofen). If a parent has noticed that the child has asthma symptoms after
eating a certain food or taking a certain medicine, these reactions should be discussed
with a doctor and they should help their child avoid any food or medicine that makes
their asthma worse.
Irritants

STRONG ODORS. Strong smells from chemicals, pesticides, paints, perfumes,
lotions, hair sprays and cleaning products may trigger asthma symptoms in sensitive
individuals. If possible discontinue use of strong-smelling household cleaning
chemicals and pesticides. The smell of these chemicals not only causes people with
asthma to have trouble breathing, but many of them can contain chemicals that may
be harmful for the whole family. Avoid wearing perfumes or strong smelling body
sprays around a child or adult with asthma. If someone must use any of these things,
have the person with asthma stay away until the smell has cleared.
 INFECTIONS. Viruses, colds, flu and other infections can trigger an asthma attack.
Young children with asthma are especially prone to asthma symptoms triggered by
colds and upper respiratory infections. While in most cases viral infections and colds
may be difficult to avoid, in order to reduce the chances of infection, families are
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encouraged to have their children practice good hygiene by frequent hand washing
and avoiding people who are sick. Adults with asthma are encouraged to get a flu
shot every fall, and families are encouraged to get their child a flu shot yearly to
reduce their chances of illness.
 COLD AIR. Simply going outside on a cold day can trigger asthma symptoms for
some people. To lessen the chances of having an asthma attack on those days when
going out into the cold air, it is suggested that those with asthma wear a washable
scarf over the nose and mouth. This will help warm the air they breathe and reduce
the chances of the child having an asthma attack due to the cold air.
 WEATHER CHANGES/AIR POLLUTION. Some people have trouble with their
asthma when the weather and/or humidity changes outside. For example, when it
goes from being cold to warm, or warm to cold. It is almost impossible to predict the
weather changes. If an individual has trouble with their asthma when the weather
changes, it is encouraged that they limit outdoor activities on these days. Most people
with asthma may also have trouble breathing on days when the air quality is poor.
On these days they should limit outdoor activity as well.
 EXERCISE. Physical exercise is essential to the body’s well being. Avoiding exercise is
not suggested for those with asthma as it is good for overall health. Exercise should
only be avoided if a person is currently having an asthma episode or attack. When
someone’s asthma is under control they should be able to do most things that a person
without asthma can do. Exercise can be a common trigger for all people with asthma,
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however, people who have asthma symptoms every time they exercise may have what
is called exercise-induced asthma. To avoid symptoms of asthma when exercising, the
following tips are suggested:
o
Warm up and cool down before exercise (e.g., 5 to 10 minutes of
stretching, etc.).
o
Exercise indoors on days when the air pollution is high or when pollen
levels are high (if allergic to pollen).
o
Avoid exercise in dusty places, in cold air, or on windy days.
o
Pre-medicate with quick relief medication 10 to 20 minutes before
exercise (parent/caregiver should discuss this with their child’s doctor). If the
child is still experiencing symptoms after pre-medicating they may need
to see their doctor for more medicine.
 EMOTIONS. Some emotions such as laughing hard, crying, or getting really upset can
trigger some people to have an asthma attack. It is suggested that a caregiver or
relative encourage the person to stay calm and relaxed if they notice that their
emotions are triggering asthma symptoms.
 ACID REFLUX. Some people have asthma that is triggered as a result of having acid
reflux. Acid reflux is a condition where the acid in the stomach may come back up
through the esophagus. People may feel heartburn from their chest and stomach
contents coming back up. Additionally, this reflux may cause wheezing. In order to
know if a person has acid reflux, they should discuss their symptoms with their
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doctor to determine if this condition could be what is triggering their asthma.
Sometimes when the acid reflux is treated the person’s asthma may get better.
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Home Trigger Assessment
1. Which of the following seems to trigger your child’s asthma? [CHECK ALL THAT APPLY]
[SHOW RESPONDENT FLASH
CARD]
___ cold air
___ changes in weather/humidity/temperature
___ exposure to tobacco smoke
___ common cold/flu
___ exercise, running or playing
___ smoke from a fireplace, wood-burning stove or BBQ Grill
___ cats, dogs, or other furry pets
___ birds
___ strong odors (perfumes, paints, cleaners)
___ air pollution (car exhaust, smoke from a factory, etc)
___ house dusting/vacuuming
___ damp, musty areas (moldy areas, damp carpet, sweaty walls, leaky toilets/sinks, etc)
___ pollens
___ strong emotions
___ scented candles, air fresheners, incense
___ medication (SPECIFY: ___________________________)
___ other (SPECIFY: ___________________________)
Environmental History
[IF BASELINE ASSESSMENT, SKIP TO Q3. ELSE, ASK Q2.]
1. Have you moved since the last time we spoke with you?
___ Yes
___ No [SKIP TO Q.5]
2. Do you own or rent your home? [CHECK CORRECT RESPONSE]
___ Own
___ Rent
___ Other (SPECIFY: ___________________________)
3. How long have you lived in your current home? [ENTER NUMBER OF YEARS, MONTHS OR WEEKS ON
APPROPRIATE LINE]
___ years
___ months
___ weeks
4. a. How many nights out of the week does your child sleep in this home? [IF NOT EVERY NIGHT, DISCUSS
TRIGGERS THAT MAY BE PRESENT IN THE OTHER HOMES THE CHILD IS SLEEPING AT, AND CONSIDER
CONDUCTING A HOME ASSESSMENT THERE IF POSSIBLE.]
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# nights:____________
5. How frequently is your child exposed to second hand cigarette smoke (such as on a person's clothing
or a person smoking in the same room or a different room)
___ At least once a day
___ 2-6 days a week
___ Once a week
___ More than once a month, but not every week
___ Once a month
___ Less than once a month [IF NEVER, CHECK LESS THAN ONCE A MONTH]
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
6. Does anyone who lives in your home smoke? [CHECK CORRECT RESPONSE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
7. Do you smoke? [CHECK CORRECT RESPONSE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
8. Has anyone seen roaches or evidence of roaches in your home in the past three months? [CHECK
CORRECT RESPONSE] [ASK AND OBSERVE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
9. Has anyone seen rats or mice or evidence of rats or mice in your home in the past three months?
[CHECK CORRECT RESPONSE] [ASK AND OBSERVE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ Refused
10. Do any of the rooms in your home feel moist or damp? [CHECK CORRECT RESPONSE]
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___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
11. Is there visible mold in any part of your home? [CHECK CORRECT RESPONSE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
12. a. Do you have any pets? [CHECK CORRECT RESPONSE]
___ Yes
___ No
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
[IF YES, ANSWER Q12B. ELSE SKIP TO Q13.]
b. Which pets do you have? [CHECK ALL THAT APPLY]
___ cat (How many?_________)
___ dog (How many?_________)
___ bird (How many?_________)
___ other furry pet (SPECIFY:____________________________________________)
13. How frequently is your child exposed to furry pets such as dogs, cats, hamsters, etc.? Would you say:
[CHECK CORRECT RESPONSE]
___ At least once a day
___ 2-6 days a week
___ Once a week
___ More than once a month, but not every week
___ Once a month
___ Less than once a month [IF NEVER, CHECK LESS THAN ONCE A MONTH]
___ NO CODED RESPONSE APPLICABLE (SPECIFY: ___________________________)
___ DON’T KNOW
___ REFUSED
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Home Environmental Checklist (HEC)
Participant ID# _________________
Data Collected by: _________________
Date: _____________ [MM/DD/YYYY]
Starting Time: ______:_____ AM/PM
Prior to Visit:
1. What year was the house built?* ________________ [www.newschicago.org]
[NOTE: IF HOME WAS BUILT BEFORE 1978, MAY BE AT RISK FOR LEAD PAINT]
Interviewer: for this questionnaire, the methods of getting information are:
O = observation only, A = ask client, A+O = ask and observe
A. General Building Questions
O A1. Record temperature: ___________________
O A2. Record humidity: ____________________
A A3a. Do you own or rent your home?
Own [SKIP TO A4A]
Section 8 [SKIP TO A4A]
Public or Subsidized Housing [SKIP TO A4A]
Rent [IF YES, ASK A3B]
Live with someone
Other (SPECIFY Relationship:___________________________)[SKIP TO A4]
Shelter
Other (SPECIFY: ___________________________)[SKIP TO A4]
A A3b. If you rent, does your landlord live on the premise?
Yes
No
Don’t Know
A A4. How long have you lived in your current home? [ENTER NUMBER OF YEARS, MONTHS OR WEEKS
ON APPROPRIATE LINE]
___ years
___ months
___ weeks
O A5. What type of building?
Apartment (with 6 or more units)
Walk-up (2-5 flat)
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Detached single house
Other, specify__________________
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O A6. What floor does the family live on? [CHECK ALL THAT APPLY]
Basement
First Floor
Middle Floor
Top floor
House
Other, specify ____________ ______________
O A7. What is the overall condition of the house?
Excellent
Good
Fair
Poor
O A8a. Is there accumulated garbage or debris on the outside of the property? [MORE THAN WHAT
WOULD BE PICKED UP AT WEEKLY GARBAGE COLLECTION]
Yes
No
A8b. If yes, rate the intensity:
minimal
a lot
extreme
O A9a. Is there clutter present in the home?
Yes [GO TO A9B]
No [SKIP TO A10]
A9b. If yes, rate the intensity:
minimal
a lot
extreme
A9c. What type of clutter?
Toys
Books
Clothes
Paper
Cleaning Chemicals
Book Bags
Other, ______________
Cardboard boxes
Shoes
A A10. Has your home ever been tested for lead?
Yes
No
Don’t Know
O A11. Is there evidence of chipped paint in the home (observe around windowsills, on painted walls, on
the floor near windows and walls)
Yes
No
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FOR INTERVIEWER TO READ: The purpose of this interview is to collect information about
your home environment as it relates to [your child’s] asthma and safety. Some of the
questions are designed to help guide the type of help you will receive. Other questions
are for research purposes and will help us figure out what kind of help to give all families
who have a child with asthma. You don’t have to answer any question you don’t want to.
If there is a question you do not want to answer, please let me know and we can skip it.
All of your responses are confidential and will not affect any of the services you receive
at the clinic or from your provider. After the interview questions, we will walk through
several rooms in the house with you to make some observations. The rooms we are
interested in looking at are your child’s bedroom, the living room, the kitchen, and the
bathroom.
B. GENERAL QUESTIONS
FOR INTERVIEWER TO READ: The purpose of the following questions is to look at the environment in your
home and how it relates to your child’s asthma as well as the health of other household members.
A B1a. First, I would like to know if you did any cleaning to prepare for this visit?
Yes
No [SKIP TO B2]
B1b. If yes, how much time did you spend on it: _______ Hours_______ Min
A B2. How many bedrooms are in the home? A bedroom is a room with a window and closet.
#__________
(ENTER “0” FOR STUDIO IN WHICH ONE OR MORE PEOPLE SLEEP)
A B3. Not counting bathroom(s), how many rooms are in the home? #__________
A B4. How many people usually live in the home, including yourself:
a. ___ Children less than 2 years old
b. ___ Children 2-12 years old
c. ___ Adolescents 13-17 years old
d. ___ Adults 18-64 years old
e. ___ Seniors 65 years and older
A B5. Where does your CHILD usually sleep?
Bedroom
Parent’s room
Grandparent’s room
Living room/family room
Other, Specify______________________________
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CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
C. DUST AND CLEANING
For interviewer to read: Next, I would like to ask you some questions related to dust, cleaning, and
washing.
A C1a. Some people use bleach to get rid of mold. Have you ever used bleach to get rid of mold?
Yes
No [SKIP TO C2]
C1b. If yes, how much bleach do you add to a gallon of water to make a mold cleaning solution?
[READ RESPONSES] (A gallon is the size of a plastic milk jug.)
Half and Half
Tablespoon
1 or 2 Cap full
Quarter cup
½ Cup
Cup*
Quart
½ Gallon
Gallon
Other, Specify ________________________
Don't use bleach
DON'T KNOW
A C2. When people come into your house, do they usually:
a. Remove their shoes?
Yes
b. Use doormat or hall rug to wipe their feet?
Yes
No
No
A + O C3a. Do you now have a working vacuum cleaner in the house?
Yes [IF YES, ASK TO SEE THE VACUUM CLEANER AND CONTINUE TO C3B.]
No [SKIP TO C4]
A C3b. How often do you change the bags?
Once a month
Once a year
When it’s full
Bagless
Never
DON’T KNOW
O C3c. Does it have a power head?
Yes
No
Don’t know
O C3d. Does the vacuum have a special air filter, such as a HEPA filter, to keep dust in the
vacuum?
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CHICAGO Trial Community Health Worker Curriculum
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Yes
No
Don’t know
FOR INTERVIEWER TO READ: The next questions are about things you did to clean your house during the last
30 days. [ENTER NUMBER OF DAYS, IF NONE=0, DK=99]
During the LAST 30 DAYS, how many times did you or any one in the home
A C4. Vacuum / sweep the floor of the room in which your CHILD sleeps? #_____/30
A C5. Vacuum or wash the cloth-covered furniture in the home? #______/30
(if no cloth covered furniture, enter 98)
A C6a. Dust the room in which your CHILD sleeps? #______/30
[IF 0 SKIP TO C7. OTHERWISE ASK C6B].
A C6b. Do you usually dry dust or wet dust the room where your child sleeps?
Dry
Wet
A C7a Scrub the tub in the bathroom? # _____/30
A C7b Scrub the shower wall in the bathroom? # _____/30
A C8.
Yes
No
In general, what do you use to scrub the tub or shower wall in the bathroom?
[Read choices]
a. Tilex or other store bought cleaner…….
b. Bleach and water solution
c. Detergent and water............................
d. Plain water..........................................
e. Murphey’s Oil Soap and Baking Soda mix / green cleaning technique
f. Vinegar and water
g. Pine-Sol Cleanser
h. Lysol
i. 409 or other store bought cleanser
j. Fabulouso
k. Comet/Ajax Kitchen Cleanser
l. Soft Scrub
m. Spic and Span
n. Other....................................................
Specify____________________________________________________________________
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CHICAGO Trial Community Health Worker Curriculum
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During the LAST 30 DAYS, how many times did you or any one in the home…
[RECORD THE HIGHEST # OF TIMES FOR ANY OF THESE CLEANING ACTIONS (# TIMES / 30 DAYS). RECORD 99 IF DON’T
KNOW]
A C9. Sweep, dust or vacuum the kitchen or cooking area floor? # ______/30
A C10. Mop the kitchen or cooking area floor? # ______/30
A C11. Clean the kitchen counter? # _______/30
A C12. In general, how do you clean the kitchen counter? (Read choices)
Yes
No
a. 409 or other store bought cleaner…….
b. Bleach and water solution .....................
c. Detergent and water............................
d. Plain water..........................................
e. Murphy’s Oil Soap / green cleaning technique
f. Vinegar and water
g. Pine-Sol Cleanser
h. Lysol
i. Mr. Clean
j. Fabulouso
k. Comet/Ajax Kitchen Cleanser
l. Soft Scrub
m. Spic and Span
n. Other....................................................
Specify_____________________________
A C13. Wash / change your child’s sheets and pillowcases? # ________/30
A C14. Wash your child’s pillows? # _______/30 [IF NO PILLOWS, ENTER 98]
A C15. Where do you usually do your laundry?
At home in your unit
In the building laundry room
In another home
In a Laundromat
Other, specify _______________________________________________________
A C16. When you wash the CHILD’s sheets and pillow cases what temperature do you use for the
a. Wash cycle?
Hot
Warm
Cold
Don’t Know
b. Rinse cycle?
Hot
Warm
Cold
Don’t Know
63
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
FOR INTERVIEWER TO READ:
The next set of questions will be about the last 12 months.
During the last 12 months or one year prior to today, how many times did you
A C17. Wash the cover on your child’s bed (i.e. blankets/spreads/ comforters)?
Number of times #_________
Other, Specify____________________________
DON’T KNOW
A C18. Clean your carpets by: [READ CHOICES]
a. No Carpet in home
b. Steam cleaning #_________
c. Shampooing #_________
d. Other # _________ Specify______________________
e. Did not clean carpets except vacuuming
A C19. How do you clean area rugs? (Check all that apply)
a. No area rug [SKIP TO SECTION D]
b1. Vacuum surface
b2. How often _______ / year
c1. Vacuum both sides
c2. How often _______ / year
d1. Shake
d2. How often _______ / year
e1. Send out
e2. How often _______ / year
f1. Wash
f2. How often _______ / year
g1. Other, Specify_____________________ g2. How often _______ / year
h. Don’t clean them
D. VENTILATION AND MOISTURE
FOR INTERVIEWER TO READ: Next are some questions about ventilation and moisture in your home.
A D1a. First, how often do windows other than bathroom and kitchen fog/steam up? Would you say: (Read
responses)
Never
Rarely
Sometimes
Most of the time Always
DON’T KNOW
A D1b First, how often do windows other than bathroom and kitchen appear frosted up? Would you say:
(Read responses)
Never
Rarely
Sometimes
Most of the time Always
DON’T KNOW
A D2. Does the bathroom window or mirror stay fogged up for more than 15 minutes
after the shower is used?
Yes
No
DON’T KNOW
A + O D3. Do you use a humidifier/vaporizer in the home?
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Yes
No
DON’T KNOW
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
A + O D4. Do you have a working air conditioner in the home?
[ IF NO, SKIP TO NEXT SECTION, E. PETS AND PESTS]
Yes
No
DON’T KNOW
A + O D5. If yes, do you use the air conditioner in the summer?
Yes
No
DON’T KNOW
A + O D5b. What type of air conditioner is used?
Central
Window Unit
A D5d. How often is the air conditioner filter changed/ cleaned?
Monthly
Yearly
Never
Don’t know
E. PETS AND PESTS
For interviewer to read: Next I would like to ask you some questions about pets, roaches, and mice or
rats.
A + O E1. Do you have any pets?
[IF YES, ANSWER E2. ELSE SKIP TO E3.]
Yes
No
DON’T KNOW
A + O E2. Which pets do you have? [CHECK ALL THAT APPLY]
cat (How many?_________)
dog (How many?_________)
bird (How many?_________)
other furry pet (SPECIFY:____________________________________________)
A + O E2b. Does the pet come into the child’s sleeping room?
Yes
No [SKIP TO Q E3.]
DON’T KNOW [SKIP TO Q E3.]
REFUSED
A + O E2c. If yes, does the CHILD ever sleep with the pet?
Yes
No
DON’T KNOW
REFUSED
A + O E3. Have you seen any roaches in your home during the past three months?
Yes
No
DON’T KNOW
A E4. Has your home been treated by a pest control company for roaches during the past
year?
Yes
No
DON’T KNOW
A E5a. Have you personally treated your home for roaches in the past year?
Yes
No [IF NO, SKIP TO E6]
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CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
© 2014
A + O E5b. If yes, what did you use to treat your home for roaches? (Check all that apply)
Dry powder
Roach bait trap
Spraying
Gel
Other, Specify:___________________________________
DON’T KNOW
A + O E6. Have you had any problems with mice or rats in your home during the past three
months?
Yes
No
DON’T KNOW
A E7a. Have you personally treated your home for rats or mice in the past year?
Yes
No [IF NO, SKIP TO E8]
A + O E7b. If yes, what did you use to treat your home for rats and mice? (Check all that apply)
Baits
Traps
Glue Traps
Poison
Steel Wool
Cat
Cover entry area/Plugged in /Steel Wool
Other, Specify:___________________________________
DON’T KNOW
A E8. Has your home been treated by a pest control company for rats or mice in the past year?
Yes
No
DON’T KNOW
HOME WALK-THROUGH
For interviewer to read: Now I would like to walk through several rooms of your home with you. I will be
making observations, looking under sinks in the kitchen and bathroom, and recording information about
these rooms. I will also be asking you questions related to specific items in some of the rooms we will be
surveying. Is it okay to start with [your/your child’s] bedroom?
F. [CHILD’S] BEDROOM / SLEEPING AREA [i.e., the person with asthma]
F1.
Assessed
Not Assessed
A + O F2. What does the CHILD usually sleep on?
Bed with mattress
Mattress on floor
Crib
Play Pen
Blanket on floor
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Air Mattress
Couch
On floor
No bed
CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
© 2014
Other, Specify_______________________________
A + O F3. Does the object (bed, mattress, etc.) on which the CHILD usually sleeps have a zippered allergy
control cover?
Yes
No
A + O F4. What kind of blanket does the CHILD use?
Cotton Blanket
Feather comforter
Wool
Fleece
None
Other, specify: ________________________________________
A + O F5a. What kind of pillow does the child sleep on?
No Pillow [SKIP TO F6a]
Synthetic Fill
Foam Rubber
Feather
Cotton
Satin
Other, specify: __________________________________________________________
A + OF5b. Does the pillow have a zippered allergy control cover?
Yes
No
No pillow
Mark Correct Answer
O F6a. Type of floor covering in your child’s bedroom:
Carpeting [IF YES, CONTINUE]
Hardwood, tile, linoleum or vinyl [SKIP TO F7A]
Other [SKIP TO F8A]
O F6b. Carpet type:
Level loop
Shag
O F6c. Is the carpet damp to touch?
Yes [GO TO F6D]
No [SKIP TO F6E]
A F6d. If yes, has the carpet been damp to touch for more than 48 hours?
Yes
No
O F6e. How old is the carpet?
Less than 2 years
3-5 years
DON’T KNOW
REFUSED
F7a. Area rugs?
Yes
F7b. If yes, % of floor area covered
6-10 years
10+ years
No
1/4
1/2
3/4
All
O F8a. Are there stuffed toys in the room?
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CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
© 2014
Yes
No [IF NO, SKIP TO F9]
O F8b. If yes, how many toys? #___________
A F8c. Are stuffed toys ever washed?
Yes [GO TO F8D]
No [SKIP TO F9]
A F8d. How often are stuffed toys washed?
Once a week
Every two weeks
2 times a month
Once a month
Every 2 – 3 months
Every 6 months
Once a year
Never
Other, Specify ________________
DON’T KNOW
O F9a.Can at least one window be opened?
Yes [GO TO F9B]
No [SKIP TO F10]
No, No window [SKIP TO F11]
A F9b. When weather allows, do you open the window to ventilate?
Always
Most times
Not that often
Never
O F10. Types of window covering:
Curtains/drapes
Blinds and or shades
Blanket / sheets
Paper/Plastic
None
Other, specify __________________________
Not applicable
O + A F11a. Working air cleaner in the room?
Yes [ASK F11B]
No [SKIP TO F12]
O +A F11b. Does it have a HEPA filter?
Yes
No
68
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
O F12. Level of dust on surface in the room:
Not visible Visible but minor
Substantial
O F13. Is this room above ground level?
Yes
Cannot see surface beneath dust
No
Structural problems
O F14a. Cracks (larger than thickness of a dime)
Yes
F14b. If yes, specify location:_______________________
No [SKIP TO F15A]
A F14c. Have you tried to fix the problem yourself?
Yes
No
F14d. If yes, what did you do? ____________________________________________
A F14e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
F14f. If yes, what did he/she do?
_________________________________________________________________
O F15a. Holes
Yes No [SKIP TO F16A]
F15b. If yes, specify location: _______________________
A F15c. Have you tried to fix the problem yourself?
Yes
No
F15d. If yes, what did you do?
_____________________________________________________________________
A F15e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
F15f. If yes, what did he/she do?
_________________________________________________________________
O F16a. Peeling or chipping paint
Yes No [SKIP TO F17A]
F16b. If yes, specify location:_______________________
A F16c. Have you tried to fix the problem yourself?
Yes
No
F16d. If yes, what did you do?
_____________________________________________________________________
F16e. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
DON’T KNOW
A F16f. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
F16f. If yes, what did he/she do?
_________________________________________________________________
69
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
F16g. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
DON’T KNOW
O F17a. Other
Yes No [SKIP TO F18A]
F17b. If yes, specify location:_______________________
A F17c. Have you tried to fix the problem yourself?
Yes
No
F17d. If yes, what did you do?
_____________________________________________________________________
A F17e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
F17f. If yes, what did he/she do?
_________________________________________________________________
Child’s Bedroom Mark Correct Answer
Are any of the following odors present?
Yes
No
If YES, rate intensity
Slight
Moderate Severe
O F18a. Tobacco
O F19a. Mold
O F20a. Sewer
O F21a. Fragrance (air freshener)
O F22a. Candles/incense
O F23a. Strong smelling cleaner or
chemical
O F24a. Other
F24b. If yes, specify below:
See evidence of (in the room and closet)
F25a. Water damage
F26a. Condensation (walls/windows)
F27a. Mold/ Mildew on the wall/ceiling
F28a. Mold/ Mildew on the carpet
If YES, rate intensity
Yes
No
Few
Many
Overrun
O F29a. Roaches (include eggs, feces,
insects)
O F30a. Rodents (or droppings)
O F31a. Food debris: crumbs, dirty
dishes, overflowing trash can
O F32a. Cigarette butts, ashtrays with
ashes
O
O
O
O
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CHICAGO Trial Community Health Worker Curriculum
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© 2014
G. LIVING ROOM/FAMILY ROOM
FOR INTERVIEWER TO READ: Next, let's have a look at the living room.
G1.
Assessed
Not Assessed
Same as CHILD’S sleeping area [ONLY ASSESS G2]
O G2a. Cloth-covered furniture?
Yes
No
O G2b. If yes, how many pieces? #_________
G3a. Type of floor covering in room:
Carpeting
[IF YES, CONTINNUE OTHERWISE SKIP TO G4]
Hardwood, tile, linoleum or vinyl
Other, ____________________________________________
O G3b. Carpet type:
Level loop
Shag
O G3c. Is the carpet damp to touch?
Yes [GO TO G3D]
No [SKIP TO G3E]
A G3d. If yes, has the carpet been damp to touch for more than 48 hours?
Yes
No
A G3e. How old is the carpet?
Less than 2 years
3-5 years
Don’t Know
REFUSED
G4a. Area rugs?
Yes
G4b. If yes, % of floor area covered
O G5a.Can at least one window be opened?
Yes [GO TO G5B]
No [SKIP TO G6]
6-10 years
10+ years
No
1/4
1/2
3/4
All
No, no window [SKIP TO G7]
A G5b. When weather allows, do you open the window to ventilate?
Always
Most times
Sometimes
Never
O G6. Types of window covering:
Curtains/drapes
Blinds and or shades
Blankets / Sheets
Paper/Plastic
None
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CHICAGO Trial Community Health Worker Curriculum
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Other, specify __________________________
Not applicable
O + A G7a. Working air cleaner in the room?
Yes [GO TO G7B]
No [SKIP TO G8]
O +A G7b. Does it have a HEPA filter?
Yes
No
O G8. Level of dust on surface in the room………..
Not visible
Visible but minor
Substantial
O G9. Is this room above ground level?
Yes
Cannot see surface beneath dust
No
Structural problems
O G10a. Cracks (larger than thickness of a dime)
Yes
No [SKIP TO G11A]
G10b. If yes, specify location:_______________________
A G10c. Have you tried to fix the problem yourself?
Yes
No
G10d. If yes, what did you do? ____________________________________________
A G10e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
G10f. If yes, what did he/she do?
_________________________________________________________________
O G11a. Holes
Yes No [SKIP TO G12A]
G11b. If yes, specify location: _______________________
A G11c. Have you tried to fix the problem yourself?
Yes
No
G11d. If yes, what did you do?
_____________________________________________________________________
A G11e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
G11f. If yes, what did he/she do?
_________________________________________________________________
O G12a. Peeling or chipping paint
Yes No [SKIP TO G13A]
G12b. If yes, specify location:_______________________
A G12c. Have you tried to fix the problem yourself?
Yes
No
G12d. If yes, what did you do?
_____________________________________________________________________
72
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
G12e. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
A G12f. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
G12g. If yes, what did he/she do?
_________________________________________________________________
G12h. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
O G13a. Other
Yes No [SKIP TO G14A]
G13b. If yes, specify location:_______________________
A G13c. Have you tried to fix the problem yourself?
Yes
No
G13d. If yes, what did you do?
_____________________________________________________________________
A G13e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
G13f. If yes, what did he/she do?
_________________________________________________________________
Child’s Mark
Are any of the following odors present?
Yes
No
If YES, rate intensity
Slight
Moderate Severe
O G14a. Tobacco
O G15a. Mold
O G16a. Sewer
O G17a. Fragrance (air freshener)
O G18a. Candles/incense
O G19a. Strong smelling cleaner or
chemical
O G20a. Other
G20b. If yes, specify below:
O
O
O
O
See evidence of (in the room and closet)
G21a. Water damage
G22a. Condensation (walls/windows)
G23a. Mold/ Mildew on the wall/ceiling
G24a. Mold/ Mildew on the carpet
If YES, rate intensity
Yes
No
Few
Many
Overrun
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CHICAGO Trial Community Health Worker Curriculum
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© 2014
O G25a. Roaches (include eggs, feces,
insects)
O G26a. Rodents (or droppings)
O G27a. Food debris: crumbs, dirty
dishes, overflowing trash can
O G28a. Cigarette butts, ashtrays with
ashes
H. THE KITCHEN
For interviewer to read: Next, let’s have a look at the kitchen.
H1.
Assessed
Not Assessed
O H2. Is there a garbage bin with a lid that closes?
Yes
NO
No garbage bin
O H3. Is the garbage bin /bag/can….
Empty
Partially full
Full
Other, specify: ________________________
No garbage bin, bag or can in kitchen
A + O H4a. What kind of heat source do you cook with?
Gas [GO TO H4b]
Electric [SKIP TO H5A]
Electric or hot plate/skillet
No Stove
Other, Specify _______________ [SKIP TO H5A]
H4b. If gas, is stove ever used to heat your home?
Yes
No
DON’T KNOW
A + O H5a. Is there a hood/vent with a working fan present over the stove/oven?
(Turn on fan to test)
Yes
NO [SKIP TO H6]
H5b. Is the hood or vent over the stove ventilated to the outside?
Yes
No
Don’t know
H5c. How often is the fan or vent used when the stove is in use? Would you say:
Always
Most of the time
Sometimes
Rarely
Never
DON’T KNOW
O+ A H6. How is food generally stored in the kitchen? [CHECK ALL THAT APPLY]
All food is in the cupboards
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CHICAGO Trial Community Health Worker Curriculum
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Some food is in the cupboards
Some food on counter, on top of fridge
Food Storage Container
Other, specify: _________________________________________________________
O H7. Are there dirty dishes in the sink?
Answer
Yes
No
O H8a. Type of floor covering:
Carpeting
[IF YES, GO TO H8B OTHERWISE SKIP TO H9A]
Hardwood, tile, linoleum or vinyl
Other
O H8b. Carpet type:
Level loop
O H8c. Is the carpet damp to touch?
Shag or plush
Yes
No
A H8d. If yes, ASK: more than 48 hours?
Yes
A H8e. How old is the carpet?
Less than 2 years
3-5 years
Don’t Know REFUSED
O H9a. Area rugs?
H9b. If yes, % of floor area covered
Yes
1/4
O H10a.Can at least one window be opened?
Yes [GO TO H10B]
No [SKIP TO H11]
No
6-10 years
10+ years
No
1/2
3/4
All
No, no window [SKIP TO H12]
A H10b. When weather allows, do you open the window to ventilate?
Always
Most times
Sometimes
Never
O H11. Types of window covering:
Curtains/drapes
Blinds and or shades
Blankets / Sheets
Paper/plastic
None
Other, specify __________________________
Not applicable
O + A H12a. Working air cleaner in the room?
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CHICAGO Trial Community Health Worker Curriculum
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Yes [GO TO H12B]
No [SKIP TO H13]
O +A H12b. Does it have a HEPA filter?
Yes
No
O H13. Level of dust on surface in the room………..
Not visible
Visible but minor
Substantial
O H14. Is this room above ground level?
Yes
Cannot see surface beneath dust
No
Structural problems
O H15a. Cracks (larger than thickness of a dime)
Yes
No [SKIP TO H16A]
H15b. If yes, specify location:_______________________
A H15c. Have you tried to fix the problem yourself?
Yes
No
H15d. If yes, what did you do? ____________________________________________
A H15e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
H15f. If yes, what did he/she do?
_________________________________________________________________
O H16a. Holes
Yes No [SKIP TO H17A}
H16b. If yes, specify location: _______________________
A H16c. Have you tried to fix the problem yourself?
Yes
No
H16d. If yes, what did you do?
_____________________________________________________________________
A H16e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
H16f. If yes, what did he/she do?
_________________________________________________________________
O H17a. Peeling or chipping paint
Yes
H17b. If yes, specify location:_______________________
No [SKIP TO H18A]
A H17c. Have you tried to fix the problem yourself?
Yes
No
H17d. If yes, what did you do?
_____________________________________________________________________
H17e. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
A H17f. [IF A RENTER], Have you asked your landlord to fix the problem?
76
Yes
No
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
H17g. If yes, what did he/she do?
_________________________________________________________________
H17h. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
O H18a. Other
Yes No [SKIP TO H19A]
H18b. If yes, specify location:_______________________
A H18c. Have you tried to fix the problem yourself?
Yes
No
H18d. If yes, what did you do?
_____________________________________________________________________
A H18e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
H18f. If yes, what did he/she do?
_________________________________________________________________
Child’s Bedroom Mark Correct Answer
Are any of the following odors present?
Yes
No
Yes
No
If YES, rate intensity
Slight
Moderate Severe
O H19a. Tobacco
O H20a. Mold
O H21a. Sewer
O H22a. Fragrance (air freshener)
O H23a. Candles/incense
O H24a. Strong smelling cleaner or
chemical
O H25a. Other
H25b. If yes, specify below:
See evidence of (in the room and closet)
O H26a. Water damage
O H27a. Condensation (walls/windows)
O H28a. Mold/ Mildew on the wall/ceiling
O H29a. Mold/ Mildew on the carpet
If YES, rate intensity
Few
Many
Overrun
O H30a. Roaches (include eggs, feces,
insects)
O H31a. Rodents (or droppings)
O H32a. Food debris: crumbs, dirty
dishes, overflowing trash can
77
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
O H33a. Cigarette butts, ashtrays with
ashes
J. THE BATHROOM
FOR INTERVIEWER TO READ: Let’s visit the bathroom [CHILD] uses most
J1.
Assessed
Not Assessed
A + O J2. Number of bathrooms in home: ____________
[IF MORE THAN 1, USE EXTRA SHEET TO ASSESS 2ND BATHROOM]
O J3a. Is there a working fan in the bathroom? (TURN ON THE FAN TO TEST)
Yes No [SKIP TO J4]
A J3b. If yes, how often is the fan used during and after a shower? Would you say:
Always
Most of the time
Sometimes
Rarely
Never
DON’T KNOW
A J3c. Is the fan vented to the outside?
Yes
No
Don’t know
O J4. Are there cracks or spaces around the tub, shower or sink caused by inadequate caulking,
missing tiles, etc.?
Yes
No
O J5. Is there mold/ mildew on the shower curtain or shower door?
Yes
No
O J6a. Type of floor covering in bathroom:
Carpeting [IF YES, GO TO J6B OTHERWISE SKIP TO J7]
Hardwood, tile, linoleum or vinyl
Other
O J6b. Carpet type:
Level loop
Shag
O J6c. Is the carpet damp to touch?
Yes
No
A J6d. If yes, has it been damp for more than 48 hours?
78
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
Yes
No
A J6e. How old is the carpet?
Less than 2 years
3-5 years
Don’t Know
REFUSED
O J7a. Area rugs?
Yes
6-10 years
10+ years
No
O J7b. If yes, % of floor area covered
1/4
1/2
3/4
All
O+ A J8a. Can at least one window be opened?
Yes [GO TO HJ8B]
No [SKIP TO J9]
No, no window [SKIP TO J10]
A J8b. When weather allows, do you open the window to ventilate?
Always
Most times
Sometimes
Never
Not applicable
O J9. Types of window covering:
Curtains/drapes
Blinds and or shades
Blankets/ sheets
Paper/plastic
None
Other, specify __________________________
Not applicable
O + A J10a. Working air cleaner in the room?
Yes [GO TO J10B]
No [SKIP TO J11]
O +A J10b. Does it have a HEPA filter?
Yes
No
O J11. Level of dust on surface in the room………..
Not visible
Visible but minor
Substantial
O J12. Is this room above ground level?
79
Yes
Cannot see surface beneath dust
No
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
Structural problems
O J13a. Cracks (larger than thickness of a dime)
J13b. If yes, specify location:_______________________
Yes
No [SKIP TO J14A]
A J13c. Have you tried to fix the problem yourself?
Yes
No
J13d. If yes, what did you do? ____________________________________________
A J13e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
J13f. If yes, what did he/she do?
_________________________________________________________________
O J14a. Holes
Yes No [SKIP TO J15A]
J14b. If yes, specify location: _______________________
A J14c. Have you tried to fix the problem yourself?
Yes
No
J14d. If yes, what did you do?
_____________________________________________________________________
A J14e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
J14f. If yes, what did he/she do?
_________________________________________________________________
O J15a. Peeling or chipping paint
Yes No [SKIP TO J16A]
J15b. If yes, specify location:_______________________
A J15c. Have you tried to fix the problem yourself?
Yes
No
J15d. If yes, what did you do?
_____________________________________________________________________
J15e. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
A J15f. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
J15g. If yes, what did he/she do?
_________________________________________________________________
J15h. Was it a lead safe procedure? Probe: Did you see a lot of dust?
[IF THERE WAS A LOT OF DUST IT WAS NOT LEAD SAFE]
Yes No
Don’t Know
O J16a. Other
Yes No [SKIP TO J17A]
J16b. If yes, specify location:_______________________
A J16c. Have you tried to fix the problem yourself?
Yes
No
J16d. If yes, what did you do?
_____________________________________________________________________
80
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
A J16e. [IF A RENTER], Have you asked your landlord to fix the problem?
Yes
No
J16f. If yes, what did he/she do?
_________________________________________________________________
Child’s Bedroom
Mark Correct Answer
Are any of the following odors present?
Yes
No
Slight
If YES, rate intensity
Moderate Severe
O J17a. Tobacco
O J18a. Mold
O J19a. Sewer
O J20a. Fragrance (air freshener)
O J21a. Candles/incense
O J22a. Strong smelling cleaner or
chemical
O J23a. Other
J23b. If yes, specify below:
See evidence of (in the room and closet)
O J24a. Water damage
O J25a. Condensation (walls/windows)
O J26a. Mold/ Mildew on the wall/ceiling
O J27a. Mold/ Mildew on the shower
wall/ceiling
O J28a. Mold/ Mildew on the carpet
Yes
No
If YES, rate intensity
Few
Many
Overrun
O J29a. Roaches (include eggs, feces,
insects)
O J30a. Rodents (or droppings)
O J31a. Food debris: crumbs, dirty
dishes, overflowing trash can
O J32a. Cigarette butts, ashtrays with
ashes
81
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
K. HEAT SOURCE
[FOR INTERVIEWER TO READ]:
Next, I would like to ask you some questions about the heat sources in your home.
A K1. What is the heating source for the home?
Electric – baseboard
Electric – furnace
Gas– baseboard/vents (central air)
Radiator [SKIP TO K3]
Space heater [SKIP TO K3]
Other, specify ___________________________________ [SKIP TO K3]
A K2. When is the air filter for the heat changed?
When it’s dirty
Every 1- 3 Months
Every 4-6 Months
Every 7-11 Months
Once a year
Whenever landlord changes it
Don’t know
A+ O K3. Do you currently have working heat? [DO NOT INCLUDE STOVE]
Yes
No
L. OTHER
For interviewer to read: Now, just a few other questions.
A+O L1a. Do you have a working clothes dryer in the home?
Yes No [SKIP TO L2]
A+O L1b. Is it vented on the outside? (Check on outside wall to see if there is a vent)
Yes No Don’t know
A+O L1c. Does it have a working lint filter?
Yes No Don’t know
A+O L2. Is there paint chipping or flaking outside the home or in common hallways?
Yes No DON’T KNOW
A L3. Overall, how satisfied are you with your home?
Very satisfied
Somewhat satisfied
Somewhat unsatisfied
82
CHICAGO Trial Community Health Worker Curriculum
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Health Institute.
© 2014
Very unsatisfied
M. CHEMICALS AND IRRITANTS
A+O
M1. Are there any of the following
products used in the home?
a. Bleach products other than laundry
bleach (e.g. disinfectants, mildew
remover, tile cleaners)
b. Ammonia cleaners
c. Detergent product (Spic & Span, Mr.
Clean)
d. Cleaners (drain, oven, toilet
cleaners with DANGER sign)
e. Air fresheners/purifiers
f. Scented candles or incense
g. Adhesives (e. g. rubber cement,
plastic glue, spray-on glue)
i. Furniture polish/spray
j. Disinfectants (Lysol, Pinesol, etc.)
k. Pesticides (Specify)
l. If yes, what type of pesticide
Yes
Spray
No
Don’t know
Gel
Dry powder
Landlord
/ building
owner
Pest
Management
Company
[check all that apply]
Other,
specify:
___________
___________
___________
______
m. Who applies the pesticide?
Participant
DON’T KNOW
N. SAFETY
A+O
N1. Is lighting adequate for safety
in the following places?
a. Hallway
b. Staircase
83
Yes
No, No light
fixture
No, No light
bulbs
N/A
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014
c. Porch/front door
d. Walkway to house
A + O N2a. Is there a working smoke detector on each floor in your home?
Yes
No - battery dead
No - no detector or broken
Can’t test
DON’T KNOW
A + O N2b. When are the smoke detector batteries replaced?
Yearly (i.e., birthday, time change, etc.)
When it beeps
Only when I remember
Never
Don’t know
Only when landlord changes them
A + O N3a. Is there a working carbon monoxide detector in the home?
Yes No Don’t know
A N3b. Is it battery operated or electric?
Battery [ASK N3C.]
Electric [END HERE]
A N3c. When are the carbon monoxide detector’s batteries replaced?
Yearly (i.e., birthday, time change, etc.)
When it beeps
Only when I remember
Never
Don’t know
Only when landlord changes them
Thank you very much for allowing me to walk through your home and for answering
these questions.
TIME AT THE END OF THE INTERVIEW: ____:___AM PM
Date form entered into database: ____________________ [MM/DD/YYYY]
Data Entry Operator: __________ [INITIALS ONLY]
84
CHICAGO Trial Community Health Worker Curriculum
These materials were created by the CHICAGO Trials, based off of materials created by the Sinai Urban
Health Institute.
© 2014