NIOSH-Former Worker Questionnaire

Appendix H.2

NIOSH -Former Worker Questionnaire

(Building Related Asthma Research in Public Schools)

(New)

Form Approved

OMB No.

Expires

FORMER WORKER QUESTIONNAIRE

(To be filled in by interviewer prior to phone call)

1. Name:______________________________ ________________________________ ____

(Last Name) (First Name) (MI)

2. Home Telephone Number: (__ __ __) __ __ __- __ __ __ __

3. Since we spoke to you in DATE, have you had any of following while you were working in the school:

Symptom	Yes	No	While away from work was this symptom…
			Same	Worse	Better
3.1) Wheezing or whistling in your chest?
3.2) Chest tightness?
3.3) Shortness of breath?
3.4) Cough?
3.5) Awakened by an attack of breathing difficulty?
3.6) Shortness of breath when hurrying on level ground or walking up a slight hill?
3.7) Cough with phlegm?
3.8) Episodes of fever and chills?
3.9) Episodes of flu-like achiness or achy joints?
3.10) Unusual tiredness, fatigue, or drowsiness?
3.11) Difficulty remembering things or concentrating?
3.12) Headaches?
3.13) Stuffy, itchy, or runny nose?
3.14) Sneezing?
3.15) Dry or itchy skin?
3.16) Episodes of watery, itchy eyes?
3.17) Sore or dry throat?
3.18) Sinusitis or sinus problems?

If YES to any of 3.1 through 3.18, answer question 4. Else go to question 5.

Public reporting burden of this collection of information is estimated to average 9 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX).

4. Since you have stopped working at the school, are these symptoms the:

1.Same ___ 2.Worse ___ 3.Better ___

5.1 Has a physician ever told you that you have asthma? 1.Yes ___ 0.No ___

IF YES:

5.2 Date of diagnosis: ___ ___ / ___ ___ ___ ___

(Month) (Year)

5.3 Do you still have asthma? 1.Yes ___ 0.No ___

6. Date you started working at the school: ___ ___ / ___ ___ ___ ___

(Month) (Year)

7. Date you stopped working at the school:

___ ___ / ___ ___ ___ ___

(Month) (Year)

8. What was the reason you left your job at the school?

_____ 1. Transferred to another school

_____ 2. Laid-off or dismissed

_____ 3. Quit due to medical reasons

_____ 4. Quit for other than medical reasons

_____ 5. Retired

_____ 6. Other (please specify__________________)

_____ 7. Refused

9.1 Have you ever smoked cigarettes regularly? 1.Yes ___ 0.No ___

IF YES:

9.2 Do you still smoke cigarettes? 1.Yes ___ 0.No ___

10. Date of Birth: __ __ / __ __ / __ __ __ __

(Mo.) (Day) (Year)

11. Gender: 1.____ Male

2.____ Female

12. Ethnicity (Please choose one):

1.____ Hispanic or Latino

0.____ Not Hispanic or Latino

13. Race (Please choose all that apply):

1.____ American Indian or Alaska Native

2.____ Asian

3.____ Black or African American

4.____ Native Hawaiian or Other Pacific Islander

5.____ White

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