Form 11 Occupation

ID NUMBER:

FORM CODE: OCE VERSION: A 7/04/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 07 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Occupation Classification and

Exposures Questionnaire

ID NUMBER:

FORM CODE: OCE VERSION: A 7/04/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark a check in the appropriate box for the response. Unless instructed, mark ONLY one response.

A. Current Employment Status

1. Are you retired? No 0  GO TO QUESTION 4

Yes 1

2. In what year did you retire?

3. Before you retired, in what job did you work the majority of hours per week? ___________________

Occupation Code (Select occupation code from list A)

4. Are you a…? No Yes

a. homemaker (i.e. care for family home) 0 1

b. student 0 1

5. Please indicate your current employment status. (Mark only one)

Employed full time (>35 hours/week in

one job or more than one job 1

Employed part time (≤35 hours/week) 2

Not currently employed 3  GO TO QUESTION 28

6. How many months in a year did you work in the past year?

Months

7. In a typical week, how many days do you go to work per week?

Number of days per/week

8. How many hours does your work day usually last at your job(s)?

Hours

9. On a typical day, do you have a regular work schedule?

No 0  GO TO QUESTION 11

Yes 1

10. When do you usually begin work? : __ __

am / pm

11. When do you usually end work? : __ __

am / pm

12. How many days per month do you work extra hours beyond your usual schedule?

Days per month

13. Which of the following best describes your usual work schedule? (Mark only one)

Day shift 1

Afternoon shift 2

Night shift 3

Split shift 4

Irregular shift/on-call 5

Rotating shift 6

14. Do you ever work the late night shift (after midnight)?

No 0  GO QUESTION 16

Yes 1

15. Do you work the late night shift (after midnight)…?

On a regular basis 1

On a rotating basis 2 (Please specify): ________________________

B. Current Occupation(s)

16. In what job do you currently work the majority of your work hours per week? _____________________

Occupation Code (Select occupation code from list A)

17. How many hours per week do you work at that job? Number of hours/week

18. Do you have any other job(s) that you work at in addition to the job that you work the majority of hours per week?

No 0  GO TO QUESTION 21

Yes 1

19. How many hours per week do you work at that job? Number of hours/week

20. What do you do in that job? ____________________________

Occupation Code (Select occupation code from list A)

C. Occupational Exposures – Current Job(s)

21. At the job you currently work the majority of your work hours per week, how often is it noisy (you need to speak in a raised voice or louder to be heard when a person is two feet away)?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

22. At the job you currently work the majority of your work hours per week, how often do you wear hearing (ear) protection?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

23. At the job you currently work the majority of your work hours per week, how often are you exposed to any type of organic solvents, for example styrene, trichloroethylene, toluene, or xylene?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

24. At the job you currently work the majority of your work hours per week, how often are you exposed to metals such as manganese, lead, or mercury?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

25. In your current job(s) are you exposed to vapors, gas, dust or fumes at work?

No 0  GO TO QUESTION 27

Yes 1

26. How often do you wear a respirator while you are at your current job(s)?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

27. In your current job(s), are you exposed to any of the following? (Mark all that apply)

a. paints, varnishes, lacquers

b. glues, pastes or other adhesives

c. acids or alkalis

d. pesticides

e. dusts

f. wood dust

g. cleaning or disinfecting solutions

h. petroleum products other than solvents (like grease, oil or fuel)

i. cutting oils, machine oils, or metal working fluids

j. smoke from burning wood

k. welding fumes

l. tobacco smoke

m. vehicle exhaust

n. cooking fumes

o. solvents or degreasers

D. Occupational Exposures – Longest Held Type of Job

28. What is the type of job that you have held the longest? __________________________

Occupation Code (Select occupation code from list A)

29. In what year did you start doing that type of job? (4 digit year)

30. How many years have you done or did you do that type of job?

(Whole number between 1 and 99)

31. Is the job you currently work the majority of your work hours per week, the type of job that you have held the longest?

No 0

Yes 1  GO TO QUESTION 38

32. What is the latest year you have/had worked doing the longest held job? (4 digit year)

33. How many hours/week do you or did you work in the longest held type of job?

(Whole number between 1 and 99)

34. At that job, how often is it or was it noisy (you needed to speak in a raised voice or louder to be heard when a person was two feet away)?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

35. At that job, how often do you or did you wear hearing (ear) protection?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

36. Are you or were you exposed to vapors, gas, dust, or fumes while on that job?

No 0  GO TO QUESTION 38

Yes 1

37. What were you exposed to on that job? (Mark all that apply)

a. paints, varnishes, lacquers

b. glues, pastes or other adhesives

c. acids or alkalis

d. pesticides

e. dusts

f. wood dust

g. cleaning or disinfecting solutions

h. petroleum products other than solvents (like grease, oil or fuel)

i. cutting oils, machine oils, or metal working fluids

j. smoke from burning wood

k. welding fumes

l. tobacco smoke

m. vehicle exhaust

n. cooking fumes

o. solvents or degreasers

E. Other Job(s)

Now I am going to ask you about any other noisy jobs you have held for one year or longer.

38. Have you held any other noisy jobs (1 year or longer) where you had to speak in a raised voice (or louder) to be heard?

No 0

Yes 1

Unknown 9

List A: Occupational Codes for Question 3, 15, 19, and 27

01 Senior professional/technical worker (doctor, professor, lawyer, architect, engineer)

02 Junior professional/Technical worker (midwife, nurse, teacher, editor, photographer)

03 Administrator/executive/manager (working proprietor, government official, section chief, department or bureau director, administrative cadre, village leader)

04 Office staff (secretary, office helper)

05 Farmer, fisherman, hunter

06 Skilled worker (foreman, group leader, craftsman)

07 Non-skilled worker (ordinary laborer, construction, yard, migrant laborer)

08 Army officer, police officer

09 Ordinary soldier, policeman

10 Driver

11 Service worker (housekeeper, cook, waiter, doorkeeper, hairdresser, counter salesperson, launderer, child care worker)

12 Athlete, actor, musician

13 Other

99 Unknown

Occupation Form (OCE) Page 0 of 6