Survey on Respiratory Health

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Attachment 1 – Instrument to be cognitively tested

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 1 hour 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 03/31/2013

Survey on Respiratory Health

If Respondent is a SEIU (Service Employees International Union) Health Care Workers East (Local 1199) member, the following language will appear at the top of the instrument: “You have been selected from among members of the SEIU (Service Employees International Union) Health Care Workers East (Local 1199) to complete this survey on respiratory health. Please answer questions using an X or check mark √ to record your responses.”

If Respondent is NOT a SEIU member, the following language will appear at the top of the instrument: “Please answer questions using an X or check mark √ to record your responses.”

Medical History

1 Have you ever had any of the following medical conditions?

1.1 Chronic obstructive pulmonary disease, or COPD	___ No ___Yes
1.2 Emphysema	___ No ___Yes
1.3 Nasal or sinus allergies, including hay fever	___ No ___Yes
1.4 Eczema or any kind of skin allergy	___ No ___Yes
1.5 Allergies to animals	___ No ___Yes
1.6 Allergies to dust or dust mites	___ No ___Yes
1.7 Allergies to latex or latex-containing products (ace bandages/adhesive tape/gloves)	___ No ___Yes

2 Has your biological mother had the following medical conditions?

2.1 Asthma? ___No ___Yes ___Don’t Know

2.2 Hay fever, eczema, or skin allergies? ___No ___Yes ___ Don’t Know

3 Has your biological father had the following medical conditions?

3.1 Asthma? ___No ___Yes ___Don’t Know

3.2 Hay fever, eczema, or skin allergies? ___No ___Yes ___Don’t Know

Home

The following questions are about the house or apartment where you currently live.

4 In the last 12 months, have you observed any of the following in your house or apartment?

4.1 Water leakage or water damage indoors on walls, floors, or ceilings? ___No ___Yes

4.2 Visible mold growth (not on food) indoors on walls, floors, or ceilings? ___No ___Yes

4.3 Odor of mold or mildew (not from food)? ___No ___Yes

5 In the last 12 months, have there been any renovations or construction in your house or apartment?

___ No ___Yes

6 In the last 12 months, how often have you personally cleaned your own home?

	Never			Less than 1 day / week					1-3 days / week				4-7 days / week

IF ‘NEVER’: Go to Question 9

IF ANY ANSWER OTHER THAN ‘NEVER’: Go to Question 7

7 In the last 12 months, on how many days a week have you used the following cleaning products in your own home? Mark the single best answer for each cleaning product.

Never

Less than 1 day / week

1-3 days / week

4-7 days / week

7.1 Bleach (Clorox®)

7.2 Ammonia (Windex®, Mr. Clean Top Job®)

7.3 Any spray cleaning product

8 In the last 12 months, on how many days a week have you used air freshening sprays (like Febreze^® or Glade^®)?

		Never				Less than 1 day / week						1-3 days / week				4-7 days / week
Accidental Chemical Spill or Gas Release

9 Were you ever involved in an accidental chemical spill or gas release?

___ No ___Yes

	IF ‘NO’: Go to Question 10	IF ‘YES’:
		9.1 In what year did the most recent accidental chemical spill or gas release occur? __ __ __ __ 9.2 Where did this most recent accidental chemical spill or gas release occur? Please mark one location. ___ Home ___ Work ___ Elsewhere 9.3 What were you exposed to? Please write in answer.
		9.4 Did you have to receive medical attention because of the most recent accidental exposure? ___ No ___Yes 9.5 In the first 24 hours following the most recent accidental exposure, did you experience any respiratory symptoms such as shortness of breath, wheezing, cough, or tightness in your chest? ___ No ___Yes
		IF ‘NO’: Go to Question 10	IF’YES’:
			9.5.1 How long did these symptoms last?
			Please mark the single best answer.
			___Less than 1 week
			___1 week to 1 month
			___ More than 1 month but less than 3 months
			___3 months or longer
			___Don’t know/Don’t remember
			Go to Question 10
Employment History

History of Healthcare Work

10 Please record the age when you started working in healthcare OR the age you began as a healthcare student, whichever was earlier.

___ ___ years old

11 How many total years have you worked in healthcare? (Include years you were a healthcare student.)

__ __ total years

Current Employment

12 Are you currently employed?

___No ___Yes

IF ‘NO’: 12.1 What is your current employment status? __ Disabled __ On family leave __ On extended sick leave __ Retired __ Student __ Other, please specify: _______________________________ Go to Question 34	IF ‘YES’: Where do you currently work? If you have more than one current job, record information for the job where you work the most hours per week. 12.2. Name of hospital or medical center: __________________________________________ 12.3 Borough in New York City or city where located: __________________________________________
	Go to Question 13

13 Use the lists below to identify the 2-digit occupation code for your current job and the 2-digit unit code for where your job is located. If you have more than one current job, record information for the job where you work the most hours per week.
13.1 What is your current occupation? __ __ occupation code		13.2 In which unit do you currently work? __ __ unit code
List of 2-digit occupation codes Please select single best code for your current job and record above. 01: Disinfecting or sterilizing technician or technologist 02: Housekeeper, cleaner 03: Lab technician, technologist, or assistant in a medical or clinical laboratory 04: Nursing assistant or orderly 05: Licensed Practical or Vocational Nurse – LPN or LVN 06: Registered Nurse - RN 07: Nurse practitioner 08: Respiratory therapist or respiratory technician 09: Ward clerk 10: Other, please specify __________________________________		List of 2-digit unit codes Please select single best code for unit where you currently work and record above. 01: in hospital, administration 02: in hospital, dialysis 03: in hospital, ear, nose, and throat (ENT) 04: in hospital, education 05: in hospital, emergency room (ER) 06: in hospital, endoscopy 07: in hospital, float 08: in hospital, general or internal medicine 09: in hospital, intensive care 10: in hospital, outpatient care 11 in hospital, pediatric 12: in hospital, psychiatric 13: in hospital, pulmonary 14: in hospital, surgery or operating room 15: in hospital, other unit, please specify _______________________________________ 16: outside hospital 17: Other, please specify _______________________________________ _______________________________________

14 How many hours per week do you work in your current job? __ __ hours per week 15 What year did you begin your current job? __ __ __ __ 16 In this job, are you regularly exposed to vapors, gases, dusts, or fumes? ___ No ___Yes 17 In the last 12 months, have you observed any of the following in the area(s) where you work?
17.1 Water leakage or water damage indoors on walls, floors, or ceilings? 17.2 Visible mold growth (not on food) indoors on walls, floors, or ceilings? 17.3 Odor of mold or mildew (not from food)?	___ No ___Yes ___ No ___Yes ___ No ___Yes
18 In the last 12 months, have there been renovations or construction in, or next to, the area(s) where you work? ___ No ___Yes IF ‘NO’: Go to Question 19 IF ‘YES’: Continue with Question 18.1

18.1 Painting walls and fixtures? 18.2 Ripping out and replacing walls, woodwork, and partitions? 18.3 Ripping out and replacing floors, carpets and fixed furniture?

___ No ___Yes ___ No ___Yes ___ No ___Yes

Exposure to Disinfectant & Sterilant Products Used on Equipment and Instruments (Current Job)

19.Thinking about your current job and what you have done in this job in the last 12 months:

Do you clean medical equipment or instruments with disinfectants or sterilants such as the following chemicals (and commercial products)

• Acetic acid

• Alcohol

• Bleach or bleach solution (for example, Clorox^®)

• Enzymatic cleaners (for example, Asepti-Zyme^®, 3M Rapid Multi-Enzyme^®)

• Ethylene oxide (also called EtO)

• Formaldehyde

• Glutaraldehyde (for example, Cidex^®, ColdSport^®, Endocide^®, Glutacide^®, Hospex^®, Metricide^®, Onicide^®, Rapicide^®, Sonacide^®, Sporicidin^®, Wavicide^®)

• Hydrogen peroxide (for example, Accell^®, Optim^®, Sporox^®)

• Hydrogen peroxide and peracetic acid (for example, Acecide^®, Metrex^®, Peract^®)

• Hydrogen peroxide gas plasma (for example, Sterad^® system)

• Ortho-phtalaldehyde (for example, Cidex OPA^®)

• Peracetic acid (for example, Steris^® system)

___ No ___Yes

IF ‘NO’: GO TO QUESTION 20

IF ‘YES’: CONTINUE WITH QUESTION 19.1

19.1 What are the names of the disinfectants or sterilants you use to clean medical equipment or instruments?

Please write in brand or product names, how many hours per day and how many days per week, on average, you disinfect or sterilize medical equipment or instruments, and whether you wear gloves when using these products

Brand or Product Names	Hours per day				Days per week			Gloves Worn
	< 1	1-2	3-4	>4	1	2-3	>3	None	Nitrile	Latex or vinyl
1.
2.
3.
4.
5.
6.

19.2 Thinking about your current job and what you have done in this job in the last 12 months:

Do you ever prepare medical equipment or instruments for disinfection or sterilization? ___ No ___Yes

IF ‘NO’: GO TO QUESTION 19.3

IF ‘YES’: CONTINUE WITH QUESTION 19.2.1

19.2.1 Which tasks do you perform to prepare medical equipment or instruments for disinfection or sterilization?

Please indicate if you perform these tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, please provide answers for how many hours per day and how many days per week, on average, you perform the task.

Tasks	Do you perform this task?			Hours per day				Days per week
				< 1	1-2	3-4	>4	1	2-3	>3
Remove gross contaminants	Yes	No	If Yes 
Purge waste from scopes, instruments, or equipment by flushing	Yes	No	If Yes 
Refill or change disinfectant or sterilization solutions	Yes	No	If Yes 

19.3 Thinking about your current job and what you have done in this job in the last 12 months:

Do you ever disinfect or sterilize medical equipment or instruments using automated systems? ___ No ___Yes

IF ‘NO’: GO TO QUESTION 19.4

IF ‘YES’: CONTINUE WITH QUESTION 19.3.1

19.3.1 Which tasks do you perform to disinfect or sterilize medical equipment or instruments using automated systems?

Please indicate if you perform these tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, please provide answers for how many hours per day and how many days per week, on average, you perform the task, and answer the questions about types of controls.

Tasks

Do you perform this task?

Hours per day

Days per week

Controls

< 1

1-2

3-4

>4

1

2-3

>3

Is system enclosed?

Is local exhaust used?

Operate EtO sterilizer

Yes

No

If Yes 

Yes

No

Yes

No

Operate Plasma H2O2 Sterad® system

Yes

No

If Yes 

Yes

No

Yes

No

Operate H2O2 sterilizer

Yes

No

If Yes 

Yes

No

Yes

No

Operate Steris® system

Yes

No

If Yes 

Yes

No

Yes

No

Clean or replace equipment screens or filters

Yes

No

If Yes 

Yes

No

Yes

No

19.4 Thinking about your current job and what you have done in this job in the last 12 months:

Do you ever manually clean, disinfect, or sterilize medical equipment or instruments? ___ No ___Yes

IF ‘NO’: GO TO QUESTION 19.5

IF ‘YES’: CONTINUE WITH QUESTION 19.4.1

19.4.1 For when you manually clean, disinfect, or sterilize medical equipment or instruments, please provide answers for how many hours per day and how many days per week, on average, you perform this task.

	Hours per day				Days per week
	< 1	1-2	3-4	>4	1	2-3	>3

19.4.2 What percentage of the time do you clean, disinfect, or sterilize medical equipment or instruments using the following methods:

19.4.2.1 Sprays? ___% of time

19.4.2.2 Wipes or other methods? ___ % of time

19.5 Thinking about your current job and what you have done in this job in the last 12 months:

Do you ever disinfect or sterilize dialysis machines? ___ No ___Yes

IF ‘NO’: GO TO QUESTION 19.6

IF ‘YES’: CONTINUE WITH QUESTION 19.5.1

19.5.1 For disinfecting dialysis machines, please provide answers for how many hours per day and how many days per week, on average, you perform this task, and answer the question about local exhaust ventilation.

	Hours per day				Days per week			Controls
	< 1	1-2	3-4	>4	1	2-3	>3	Is local exhaust used?
								Yes	No

19.6 Thinking about your current job and what you have done in this job in the last 12 months:

Do you ever disinfect or sterilize portable units (for example, IV stands or carts)? ___ No ___Yes

IF ‘NO’: GO TO QUESTION 20

IF ‘YES’: CONTINUE WITH QUESTION 19.6.1

19.6.1 For disinfecting portable units, please provide answers for how many hours per day and how many days per week, on average, you perform this task, and answer the question about local exhaust ventilation

	Hours per day				Days per week			Controls
	< 1	1-2	3-4	>4	1	2-3	>3	Is local exhaust used?
								Yes	No

Exposure to Cleaning & Disinfectant Products Used on Fixed Surfaces (Current Job)
20	Thinking about your current job and what you have done in this job in the last 12 months: Do you clean and disinfect surfaces (such as floors, tables, windows, beds, chairs, bathrooms, computers, counter tops) at work with products such as: Acids Alcohol Ammonia Bleach/Chlorine (for example, Clorox®) Chloramines Detergents Floor wax stripper Phenolics (for example, 3M Phenolic Disinfectant 18®) Quaternary ammonium compounds “Quats” (for example, 3M Neutral Quat 23®, 3M HB Quat 25®, Sani-Cloth Plus®) ___ No ___Yes IF ‘NO’: GO TO QUESTION 21 IF ‘YES’: CONTINUE WITH QUESTION 20.1
20.1	What are the names of the cleaners/disinfectants you use to clean surfaces? Please write in brand or product names, how many hours a day and how many days a week, you use these cleaners/disinfectants.
Brand or Product Names		Hours per day				Days per week
		< 1	1-2	3-4	>4	1	2-3	>3
1.
2.
3.
4.
5.
6.

20.2 What tasks do you perform when cleaning and disinfecting surfaces?

Please indicate if you perform the tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, Please indicate how many hours a day and how many days a week, on average, you clean or disinfect surfaces, and the type of gloves used.

Tasks

Do you perform this task?

Hours per day

Days per week

Gloves Worn

< 1

1-2

3-4

>4

1

2-3

>3

None

Nitrile

Latex or vinyl

Manually mix, refill, or empty cleaning or disinfecting products

Yes

No

If Yes 

Clean toilet, sink, shower

Yes

No

If Yes 

Spray then wipe glass, windows, mirrors

Yes

No

If Yes 

Polish wood furniture

Yes

No

If Yes 

Polish stainless steel surfaces

Yes

No

If Yes 

Spray deodorant/ disinfectant

Yes

No

If Yes 

Mop floors

Yes

No

If Yes 

Cleanup spills or blood

Yes

No

If Yes 

Wipe down beds, furniture, counters, walls, computers, etc.

Yes

No

If Yes, answer questions to right & below

What percentage of the time when cleaning these surfaces do you use sprays ____ % and wipes ____%.

20.3 Thinking about your current job and what you have done in this job in the last 12 months:

Do you clean and wax floors using strippers and buffers?

___ No ___Yes

IF ‘NO’: GO TO QUESTION 21

IF ‘YES’: CONTINUE WITH QUESTION 20.3.1

20.3.1What tasks do you perform when cleaning and waxing floors using strippers and buffers?

Please indicate if you perform the tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, Please indicate how many hours a day and how many days a week, on average, you clean or disinfect surfaces, and the type of gloves used.

Tasks

Do you perform this task?

Hours per day

Days per week

Gloves Worn

< 1

1-2

3-4

>4

1

2-3

>3

None

Nitrile

Latex or vinyl

Strip floors

Yes

No

If Yes 

Scrape floors

Yes

No

If Yes 

Prepare to buff floors

Yes

No

If Yes 

Buff floors

Yes

No

If Yes 

Wax floors

Yes

No

If Yes 

Exposure to Chemicals Used in Laboratories (Current Job)
21	Thinking about your current job and what you have done in this job in the last 12 months: Do you use chemicals or solvents at work in the laboratory? ___ No ___Yes IF ‘NO’: GO TO QUESTION 22 IF ‘YES’: CONTINUE WITH QUESTION 21.1

21.1 What are the names of the chemicals or solvents you use in laboratories?

Please write in brand or product names, how many hours a day and how many days a week, you use these substances.

Brand or Product Names	Hours per day				Days per week			Gloves Worn
	< 1	1-2	3-4	>4	1	2-3	>3	None	Nitrile	Latex or vinyl
1.
2.
3.
4.
5.
6.

21.2 What tasks and tools do you use when you apply or use these chemicals or solvents?

Please indicate how many hours a day and how many days a week, on average, you apply or use these chemicals or solvents or metals, and the type of controls present.

Tasks

Do you perform this task?

Hours per day

Days per week

Controls

< 1

1-2

3-4

>4

1

2-3

>3

Is system enclosed?

Is local exhaust used?

Pipette samples or solutions

Yes

No

If Yes 

Yes

No

Yes

No

Place biopsy in formalin

Yes

No

If Yes 

Yes

No

Yes

No

Prepare formalin neutralizer

Yes

No

If Yes 

Yes

No

Yes

No

Test blood sample

Yes

No

If Yes 

Yes

No

Yes

No

Cut tissue samples

Yes

No

If Yes 

Yes

No

Yes

No

Prepare and fill stainer

Yes

No

If Yes 

Yes

No

Yes

No

Exposure to Products Used on Patients (Current Job)

22

Thinking about your current job and what you have done in this job in the last 12 months: Do you use chemicals, adhesives, alcohols or solvents (such as super glue, alcohols, alcohol preps, mineral spirits, toluene, solutions to remove adhesives) at work on patients? ___ No ___Yes IF ‘NO’: GO TO QUESTION 23 IF ‘YES’: CONTINUE WITH QUESTION 22.1

22.1 What are the names of the chemicals/adhesives/alcohols/solvents you use on patients? Please write in brand or product names, how many hours a day and how many days a week, you use these adhesives, alcohols, or solvents with patients

Brand or Product Names	Hours per day				Days per week
	< 1	1-2	3-4	>4	1	2-3	>3
1.
2.
3.
4.
5.
6.

22.2 What tasks do you perform when you apply or use chemicals, adhesives, alcohols, or solvents on patients?

Please indicate if you perform the tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, Please indicate how many hours a day and how many days a week, on average, you clean or disinfect surfaces, and the type of gloves used.

Tasks

Do you perform this task?

Hours per day

Days per week

Gloves Worn

< 1

1-2

3-4

>4

1

2-3

>3

None

Nitrile

Latex or vinyl

Apply disinfectant with gauze or swab

Yes

No

If Yes 

Spray disinfectant

Yes

No

If Yes 

Clean wounds

Yes

No

If Yes 

Apply adhesive for ostomy bags

Yes

No

If Yes 

Apply benzoin tincture

Yes

No

If Yes 

Exposure to Aerosolized Medicines Used with Patients (Current Job)
23	Thinking about your current job and what you have done in this job in the last 12 months: Do you administer aerosolized medications such as antibiotics (for example, Tobramycin, Amikacin, or Colistin), pentamidine (for example, Nebupent®), ribavirin, bronchodilators, anesthetics, antitrypsin)?

___ No ___Yes

IF ‘NO’: GO TO QUESTION 24

IF ‘YES’: CONTINUE WITH QUESTION 23.1

23.1 What are the names of the aerosolized medications you administer?

Please write in brand or product names, how many hours a day and how many days a week, you administer aerosolized medications

Brand or Product Names	Hours per day				Days per week
	< 1	1-2	3-4	>4	1	2-3	>3
1.
2.
3.
4.
5.
6.

23.2 What tasks and tools do you use to administer aerosolized medications?

Please indicate if you perform the tasks listed in the first column of the following table.

IF YOU ANSWER ‘YES’ FOR A TASK, Please indicate how many hours a day and how many days a week, on average, you clean or disinfect surfaces, and the type of gloves used.

Tasks

Do you perform this task?

Hours per day

Days per week

Gloves Worn

< 1

1-2

3-4

>4

1

2-3

>3

None

Nitrile

Latex or vinyl

Manage patients on ventilators or oxygen

Yes

No

If Yes 

Teach use of metered-dose inhalers or nebulizers

Yes

No

If Yes 

Apply nebulizer therapy using:

Yes

No

If Yes 

hand pumps?

Yes

No

If Yes 

automated enclosed system?

Yes

No

If Yes 

Employment 5 Years Ago

24. Were you employed 5 years ago? ___ No ___Yes

IF ‘NO’: 24.1 What was your employment status 5 years ago? __ Disabled __ On family leave __ On extended sick leave __ Retired __Student __ Other, please specify: __________________________________ Go to Question 34

IF ‘YES’: 24.2 Five years ago, were you working in the same job that you already reported as your current job? ‘Same job’ means both the occupation code and unit code are the same. ___ No ___Yes IF ‘NO’: Go to Question 25 IF ‘YES’: Go to Question 34 on Page17

25. Use the lists below to identify the 2-digit occupation code for the job you had 5 years ago and the 2-digit unit code for where the job was located.

If you had more than one job 5 years ago, record information for job where you worked the most hours per week.

25.1 What was your occupation 5 years ago? __ __ Occupation code

25.2 In which unit did you work 5 years ago? __ __ Unit code

List of 2-digit occupation codes Please select single best code for the job you had 5 years ago and record above. 01: Disinfecting or sterilizing technician or technologist 02: Housekeeper, cleaner 03: Lab technician, technologist, or assistant in a medical or clinical laboratory 04: Nursing assistant or orderly 05 : Nurse (RN, LPN) 06: Nurse practitioner 07: Respiratory therapist or respiratory technician 08: Ward clerk 09: Other, please specify _______________________________

List of 2-digit unit codes Please select single best code for the unit where you worked 5 years ago and record above. 01: in hospital, administration 02: in hospital, dialysis 03:  in hospital, education 04: in hospital, emergency room (ER) 05: in hospital, endoscopy 06: in hospital, float 07: in hospital, general or internal medicine 08: in hospital, intensive care 09: in hospital, outpatient care 10: in hospital, pediatric 11: in hospital, psychiatric 12: in hospital, pulmonary 13: in hospital, surgery or operating room 14: outside hospital 15: Other, please specify _________________________________

26 How many hours per week did you work in the job you had 5 years ago? 27 What year did you begin that job? __ __ __ __ 28 What year did you stop working in that job? __ __ __ __ 29 Were you regularly exposed to vapors, gases, dust, or fumes in that job?		__ __ hours per week ___ No ___Yes
30 Thinking about the job you had 5 years ago, did you clean medical equipment or instruments with disinfectants or sterilants such as the following chemicals (and commercial products) Acetic acid Alcohol Bleach or bleach solution (for example, Clorox®) Ethylene oxide or EtO Formaldehyde Glutaraldehyde (for example, Cidex®, ColdSport®, Endocide®, Glutacide®, Hospex®, Metricide®, Onicide®, Rapicide®, Sonacide®,Sporicidin®, Wavicide®) Hydrogen peroxide (for example, Accell®, Optim®, Sporox®) Hydrogen peroxide gas plasma (for example, Sterad® system) Ortho-phtalaldehyde (for example, Cidex OPA®) Peracetic acid (for example, Steris® system) Hydrogen peroxide and peracetic acid (for example, Acecide®, Metrex®, Peract®) __ No __Yes
30.1 In the process of disinfecting or sterilizing medical equipment or instruments, did you use an enzymatic cleaner as well?	___No ___Yes __ Don’t Know
31 Thinking about the job you had 5 years ago, did you clean surfaces (such as floors, tables, windows, beds, chairs, bathroom) at work with cleaners or disinfectants such as bleach/chlorine, ammonia, chloramines, quats, phenolics, floor stripper, acids, or detergents?		__ No __Yes
32 Thinking about the job you had 5 years ago, did you observe any of the following in the building where you worked? 32.1 Water leakage or water damage indoors on walls, floors, or ceilings? 32.2 Visible mold growth (not on food) indoors on walls, floors, or ceilings? 32.3 Odor of mold or mildew (not from food)?		__ No __Yes __ No __Yes __ No __Yes
33 Thinking about the job you had 5 years ago, were there renovations or construction at your job?		__ No __Yes

Changing Jobs

34 Have you ever had to change or leave a job or position because it affected your breathing? This would include changing jobs or positions within the same workplace.

___ No ___Yes

IF ‘NO’: Go to Question 35 on next page	IF ‘YES’: If you have changed or left a job or position more than once because it affected your breathing, please answer the following questions about the most recent time this happened.
	34.1 In which year did you change or leave this job or position? ___ ___ ___ ___
	34.2 Concerning the job or position you changed or left:
	34.2.1 What kind of job or position did you change or leave? __________________________________________________________
	34.2.2 In what industry was this job or position you changed or left? __________________________________________________________
	34.2.3 What had you done in the job or position you changed or left? __________________________________________________________
	34.2.4 What exposure or activity affected your breathing in the job or position you changed or left? __________________________________________________________
	34.3 Concerning the job or position you went to:
	34.3.1 What kind of job or position did you go to? __________________________________________________________
	34.3.2 In what industry was the job or position you went to? __________________________________________________________
	34.3.3 What did you do in this new job or position? __________________________________________________________

Demographics

35 In what year were you born? __ __ __ __

Year

36 What is your sex? ___ Male ___Female

37 Do you consider yourself of Hispanic, Latino, or Spanish origin? Mark the single best answer.

___ No ___ Yes

IF ‘NO’: Go to Question 38	IF ‘YES’: 37.1 Which of the following best describes your Hispanic, Latino, or Spanish origin? (Mark only one)
	___ Mexican, Mexican American, Chicano
	___ Puerto-Rican
	___ Cuban ____Another Hispanic, Latino, or Spanish origin
	If other, please specify: __________________________________________

38 What is your race? Mark one or more in the list below.

___ White

___ Black, African American

___ American Indian or Alaska Native

___Asian Indian

___Chinese

___Filipino

___Japanese

___Korean

___Vietnamese

___Native Hawaiian

___Guamanian or Chamorro

___Samoan

___Other Pacific Islander – Specify: _________________________________________

___Some other race - Specify: ______________________________________________

39 What is the highest grade or level of education that you have completed?

___ Less than a high school diploma

___ High school diploma or GED

___ Some college or vocational/technical education

___ 4 year college graduate (Bachelor’s degree)

___ Graduate/Medical/Law school

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