NIOSH-Health Questionnaire

Appendix H.3

NIOSH-Health Questionnaire

(Building Related Asthma Research in Public Schools)

(New)

Form Approved

OMB No.

Questionnaire Administered by School Nurse

(NO DATA COLLECTION REQUIRED)

HEALTH QUESTIONNAIRE

1. Survey Date: __ __/__ __/2008

2. Name: _________________ ______ _______________________

First MI Last

3. Have you had wheezing or whistling in your chest one or more times per 1.Yes ___ 0.No ___

week in the last 4 weeks?

4. Have you had chest tightness one or more times per week in the last 4 weeks? 1.Yes ___ 0.No ___

5. Have you had shortness of breath one or more times per week in the last 4 weeks? 1.Yes ___ 0.No ___

6. Have you had a cough one or more times per week in the last 4 weeks? 1.Yes ___ 0.No ___

7. Have you had watery or itchy eyes one or more times per week in the 1.Yes ___ 0.No ___

last 4 weeks?

8. Have you had a stuffy, itchy or runny nose one or more times per week in the 1.Yes ___ 0.No ___

last 4 weeks?

9. Have you had a sore or dry throat one or more times per week in the last 4 weeks? 1.Yes ___ 0.No ___

10. Have you had a headache one or more times per week in the last 4 weeks? 1.Yes ___ 0.No ___

11. Have you had difficulty remembering things or concentrating one or more times 1.Yes ___ 0.No ___ per week in the last 4 weeks?

12. Have you had unusual tiredness, fatigue, or drowsiness one or more times per 1.Yes ___ 0.No ___

week in the last 4 weeks?

13. Have you had sinusitis or sinus problems in the last 4 weeks? 1.Yes ___ 0.No ___

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

IF YES:

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

15. Please indicate your current job title: 1._____Teacher

2._____Teacher’s Aide

3._____Office Staff

4._____Administration

5._____Maintenance

6._____Custodian

7._____School Nurse

8._____Cafeteria/Kitchen Worker

9._____Librarian

10.____Other (specify______________)

16. Please list the room numbers (or, if no room number, room names) where you have spent most of your time in the last 4 weeks while at the school (please list in order starting with where you spent most of your time): ___________________

___________________

___________________

___________________

___________________

THANK YOU FOR YOUR TIME!

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