Instructions to Interviewers Please administer this surveyto the child146s primary caregiverduring suspect spices herbal remedies or imported drinks may be the child146s source of lead exposureIf poss ID: 862615
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1 ��NCLEAD Child ID:________
��NCLEAD Child ID:________________________COUNTY: ________________________ATE_________________________________INTERVIEWER: __________________________��1 &#x/MCI; 0 ;&#x/MCI; 0 ;Spiceand Home RemedySurvey Instructions to Interviewers: Please administer this surveyto the child’s primary caregiverduring suspect spices, herbal remedies, or imported drinks may be the child’s source of lead exposure.If possible, take pictures of the food labelson the front and back of each product,for any samples you collect.If parent cannot tell you exactly how much of a substance thechildeat, please have them show you how they measure it and then you can estimate the amount. Does esyour child eatanyfoods prepared withherbs,spices If no, do you prepareseparate foodsthat have no spicesfor your child………………………………………….………&
2 #133;… ��NCLEAD
#133;… ��NCLEAD Child ID:________________________COUNTY: ________________________ATE_________________________________INTERVIEWER: __________________________��2 &#x/MCI; 0 ;&#x/MCI; 0 ;Instructions for Interviewers: Recordthe following information about the herbsspicesand supplementsthat you sample Herb/ Spice/ Supplement Name Brand Name Lot number How acquired? (Check One) Purchased in USA? �If purchased in USA or online, write Store Name, Address, City, State below � If purchased outside of , write country of purchase below Purchased Sent by family/ friends Yes No Purchased Sent by family/ friends Yes No Purchased Sent by family/ friends Yes No Purchased Sent by family/ friends Yes No Purchased Sent by family/ friends Yes No Purchased Sent by family/ friends Yes No