Health Hazard Evaluation Specific Questionnaire (Example)

Attachment G OMB #0920-0260

Expir._____

TB Questionnaire Meridian Fire Dept HETA 20070012

1. Demographics

Name

DOB

Address/phone #

2. Job History

Length of time employed with Meridian Fire Dept

• What station house do you work in?

• Have you worked in different station houses in the past? If so, when and for how long?

• Do you cover shifts in other stationhouses? If so, how often?

• When responding to calls where patients exhibit respiratory signs consistent with TB, due you use respiratory protection

• If medical condition allows, are masks placed on patients with risk factors for active TB before ambulance transport arrives

• Did you respond to area shelters during hurricane evacuations over the past year (Katrina)

• If yes, do you remember responding to patients with respiratory signs or potential TB risk factors

Public reporting burden of this collection of information is estimated to average 30 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).

Other employment concurrent with present job (focus on jobs placing individual at increased risk)

-if yes, what type and how long

- for volunteer fire work, do you perform EMT duties

- are you involved in patient transport by ambulance- if so, approximate # runs annually

Prior employment (focus on employment in higher risk jobs such as hospital work, EMS with ambulance transport, prisons, shelters, etc..)

-list prior jobs and approximate period of employment

3. Other activities

Involvement in outdoor activities such as hunting, fishing, gardening or farming

Have you volunteered your time/been in contact with the following groups of people

-homeless shelters, prisons, elderly, other groups at risk for active TB

4. Tuberculosis Risk Factors

What country were you born in?

Any known prior contact with an active case of tuberculosis

-includes patients, family members, or other close personal contacts

History of foreign travel

• if yes, what countries and approximate dates of travel and length of stay

• did you have close contact with local population (humanitarian/missionary work involving church groups or patient care)

5. Medical History

Do you currently or have you had in the past any medical conditions (diabetes, other lung disease, blood disorders, cancer, diseases that suppress the immune system) or taken drugs for medical conditions that suppress the immune system (prolonged corticosteroids, chemotherapy/radiation, etc.)

Do you currently have symptoms of TB illness (cough, chest pain, coughing up blood, fever, chills, night sweats, appetite or weight loss, excessive tiredness)

Tobacco use

• Do you smoke? If so, approx. # cigarettes/cigars/pipe per day

• If no, have you ever smoked in the past? If so, how much and for how long/when did you quit?

• Do you use smokeless tobacco products (chewing tobacco, skoal, etc?)

Alcohol

• Do you drink alcohol? If so, approx. # drinks weekly

• If no, did you drink alcohol in the past? Approx. # drinks/week for how long and when did you quit?

Have you ever tested positive on TB skin testing before your latest test?