Form Attachment 1 Attachment 1 Respiratory Health Internet Version

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Attachment 1 – Respiratory Health Internet version to be cognitively tested

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

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 only for statistical purposes 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 60 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

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?

27.1 Chronic obstructive pulmonary disease, or COPD	No Yes
27.2 Emphysema	No Yes
27.3 Nasal or sinus allergies, including hay fever	No Yes
27.4 Eczema or any kind of skin allergy	No Yes
27.5 Allergies to animals	No Yes
27.6 Allergies to dust or dust mites	No Yes
27.7 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 8

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 Any spray cleaning product
7.2 Bleach like Clorox®
7.3 Ammonia products, like Mr. Clean Top Job®
7.4 Window cleaners, like Windex®
7.5 Air freshening sprays, like Febreze® or Glade®

Accidental Chemical Spill or Gas Release

8 Were you ever involved in or near an accidental chemical spill or gas release? No Yes

IF ‘NO’: Go to Question 9	IF ‘YES’:
	8.1 In what year did the most recent accidental chemical spill or gas release occur? __ __ __ __ 8.2 Where did this most recent accidental chemical spill or gas release occur? Please mark one location. Home Work Elsewhere 8.3 What were you exposed to? Please write in answer.
	8.4 Did you have to receive medical attention because of the most recent accidental exposure? No Yes 8.5 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 9	IF’YES’:
		8.5.1 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

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

___ ___ years old

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

__ __ total years

Current Employment

11 Are you currently employed?

No Yes

IF ‘NO’: 11.1 What is your current employment status? Please mark the single best answer. Disabled On family leave On extended sick leave Retired Student Other, please specify: _______________________________ Go to Question 25	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. 11.2. Name of hospital, nursing home or other facility: __________________________________________ 11.3 City where located or borough in New York City: __________________________________________
	Go to Question 12

12 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.
12.1 What is your current occupation? __ __ occupation code		12.2 In what type of facility do you currently work? __ __ facility code
List of 2-digit occupation codes Please select single best code for your current job and record above. 01: Medical instrument preparers or endoscopy technician 02: Environmental service worker, housekeeper, or cleaner 03: Lab technician, lab technologist, or assistant in a medical or clinical laboratory 04: Nursing assistant, nurse technician, nurse support assistant, patient care technician, patient support or orderly 05: Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (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 facility codes Please select single best code for type of facility where you currently work and record above. 01: Hospital 02: Nursing Home 03: Other, please specify _______________________________________ _______________________________________

12.3 Use the lists below to identify the 2-digit location 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.
	12.2 Where is your work location? __ __ location code
	List of 2-digit location codes Please select single best code for the location where you currently work and record above. 01: Patient care ward 02: Administration 03: Central supply 04: Dental 05: Dialysis 06: Ear, nose, and throat (ENT) 07: Education 08: Emergency room (ER) 09: Endoscopy 10: Float or multiple locations 11: General or internal medicine 12: Intensive care 13: Labor and delivery 14: Outpatient care 15 Pediatric 16: Psychiatric 17: Pulmonary 18: Surgery or operating room 19: Other location, please specify ____________________________________________ _______________________________________

13 How many hours do you typically work per week in your current job? __ __ hours per week 14 What year did you begin your current job? __ __ __ __ 15 In this job, are you regularly exposed to vapors, gases, dusts, or fumes? No Yes IF ‘NO’: Go to Question 16 IF ‘YES’: Continue with Question 15.1 15.1 To what vapors, gases, dusts, or fumes are you exposed regularly? _______________________ 16 In the last 12 months, have you observed any of the following in the area(s) where you work?
16.1 Water leakage or water damage indoors on walls, floors, or ceilings? 16.2 Visible mold growth (not on food) indoors on walls, floors, or ceilings? 16.3 Odor of mold or mildew (not from food)?	No Yes No Yes No Yes
17 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 18 IF ‘YES’: Continue with Question 17.1

17.1 Painting walls and fixtures? 17.2 Ripping out and replacing walls, woodwork, and partitions? 17.3 Ripping out and replacing floors, carpets, and fixed furniture?

No Yes No Yes No Yes

Use of Hand Sanitizers
18. How many times per day, both at home and at work, do you disinfect your hands with liquid hand sanitizers?
Never	Less than 1 time per day	1-3 times per day	4-10 times per day	More than 10 times per day

Sterilizing Medical Instruments (Current Job)

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

Do you sterilize or high-level disinfect medical instruments, including dental instruments or ventilator parts, in central supply or other locations such as endoscopy and bronchoscopy units, hemodialysis units, operating rooms, or other clinical settings?

No Yes

IF ‘NO’: GO TO QUESTION 20

IF ‘YES’: CONTINUE WITH QUESTION 19.1

19.1 What are the names of the sterilants or high-level disinfectants you use to sterilize medical instruments?

Please indicate any brand or product from the list and write in brand or product names if you use any sterilants not listed. IF YOU ANSWER ‘YES’ FOR A BRAND OR PRODUCT, please indicate how many days per week you use those products and the type of gloves used.

Chemical or Product Names

Do you use this chemical or product?

Days per week

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Acetic acid

No

Yes

Don’t Know

If Yes 

Alcohol, such as ethanol or isopropanol

No

Yes

Don’t Know

If Yes 

Bleach or chlorine such as Chlorox®

No

Yes

Don’t Know

If Yes 

Enzymatic cleaners, such as Asepti-Zyme®, 3M Rapid Multi-Enzyme®

No

Yes

Don’t Know

If Yes 

Ethylene oxide in compressed-gas cylinders or single-dose cartridges

No

Yes

Don’t Know

If Yes 

Ethylene oxide in glass ampules

No

Yes

Don’t Know

If Yes 

Formaldehyde

No

Yes

Don’t Know

If Yes 

Glutaraldehydes such as Cidex®, Metricide®, Rapicide®, Wavicide®,

No

Yes

Don’t Know

If Yes 

Glutaraldehyde and isopropanol combinations such as Aldahol III®,

No

Yes

Don’t Know

If Yes 

Glutaraldehyde and phenol/phenate combinations such as Sporicidin®

No

Yes

Don’t Know

If Yes 

Hydrogen peroxides such as Accell®, Optim®, Resert XL®, Sporox®

No

Yes

Don’t Know

If Yes 

Hydrogen peroxide and peracetic acid combinations such as Acecide®, EndoSpor Plus®, Metrex®, Peract®

No

Yes

Don’t Know

If Yes 

Hydrogen peroxide gas plasma such as Sterad®

No

Yes

Don’t Know

If Yes 

Hypochlorite or Hypochlorous acids such as Sterilox®

No

Yes

Don’t Know

If Yes 

Ortho-phthalaldehydes such as Cidex OPA®, Opaciden®

No

Yes

Don’t Know

If Yes 

Peracetic acid such as Steris®

No

Yes

Don’t Know

If Yes 

Days per week

Gloves Worn

Please write any other sterilizing or high-level disinfecting chemicals or product names you use to sterilize medical instruments

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

1.

2.

3.

4.

5.

6.

19.2 On a typical day when you use sterilants or high-level disinfectants, how many times per day do you use these products?

Less than 1 time per day	1-3 times per day	4-10 times per day	More than 10 times per day

19.3 On a typical day when you use sterilants or high-level disinfectants, how many hours per day do you use these products?

Less than 1 hour per day	1-4 hours per day	More than 4 hours per day

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

Do you ever prepare medical instruments for sterilization?

No Yes

IF ‘NO’: GO TO QUESTION 45.5

IF ‘YES’: CONTINUE WITH QUESTION 45.4

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

Do you ever prepare medical instruments for sterilization by manually disassembling instruments, removing gross contaminants, or flushing gross contaminants and waste?

No Yes

IF ‘NO’: GO TO QUESTION 19.5

IF ‘YES’: CONTINUE WITH QUESTION 19.4.1

19.4.1 When you remove gross contaminants and waste from scopes and instruments, please indicate how many

days per week, times per week, duration of task and the type of gloves used when you perform this task.

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

__ __

_____ hrs min

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

Do you ever prepare medical instruments for sterilization by refilling or changing sterilization solutions?

No Yes

IF ‘NO’: GO TO QUESTION 19.6

IF ‘YES’: CONTINUE WITH QUESTION 19.5.1

19.5.1 When you refill or change sterilization solutions, please indicate how many days per week, times per week,

duration of task and the type of gloves used when you perform this task.

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

__ __

_____ hrs min

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

Do you ever manually sterilize medical instruments?

No Yes

IF ‘NO’: GO TO QUESTION 19.7

IF ‘YES’: CONTINUE WITH QUESTION 19.6.1

19.6.1 When you manually sterilize medical instruments, please indicate how many days per week, times per

week, duration of task and the type of gloves used when you perform this task.

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

____ __

_____ hrs min

19.6.2 Do you use a sterilants immersion container when you sterilize or high-level disinfect medical instruments?

No Yes

IF ‘NO’: GO TO QUESTION 19.7

IF ‘YES’: CONTINUE WITH QUESTION 19.6.2.1

19.6.2.1 When using a sterilants immersion container please select all conditions below that apply.

Enclosed box or exhaust hood used

Emersion box equipped with a tight fitting lid

Local exhaust ventilation is used in room

None of the conditions apply

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

Do you ever sterilize medical instruments using automated systems? No Yes

IF ‘NO’: GO TO QUESTION 20

IF ‘YES’: CONTINUE WITH QUESTION 19.7.1

19.7.1 Which tasks do you perform to sterilize medical 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 indicate how many days per week, times per day, duration of task, and the type of controls used.

Tasks

Do you perform this task?

Days per week

Times per day

Duration of Task

Controls

Less than 1

1

2

3

4

5

6

7

Is system enclosed?

Is local exhaust ventilation used?

Operate Ethylene Oxide sterilizer

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

Operate Plasma Hydrogen Peroxide Sterad® system

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

Operate Steris® system

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

Conduct maintenance on systems such as cleaning or replacing screens or filters

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

19.8 Do you rinse or flush sterilized medical instruments with alcohol?

No Yes

IF ‘NO’: GO TO QUESTION 20

IF ‘YES’: CONTINUE WITH QUESTION 19.8.1

19.8.1 After rinsing or flushing with alcohol do you use forced air to dry medical instruments?

No Yes

Cleaning Fixed Surfaces, Equipment or Instruments (Current Job)

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

Do you clean or disinfect fixed surfaces, equipment, or instruments?

Examples of fixed surfaces are: countertops, floors, beds, and bathrooms.

Examples of equipment are: IV poles, monitors, carts, and computers.

Examples of instruments are: blood pressure cuffs, and stethoscopes.

No Yes

IF ‘NO’: GO TO QUESTION 21

IF ‘YES’: CONTINUE WITH QUESTION 20.1

20.1 What cleaners or disinfectants do you use for cleaning fixed surfaces, equipment, or instruments?

Please indicate any brand or product from the list and write in brand or product names if you use any cleaner or disinfectant not listed. IF YOU ANSWER ‘YES’ FOR A BRAND OR PRODUCT, Please indicate how many days per week, times per week, duration of product use, and the type of gloves used.

Chemical or Product Names

Do you use this chemical or product?

Days per week

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Glass cleaning products such as Windex®

No

Yes

Don’t Know

If Yes 

Acids

No

Yes

Don’t Know

If Yes 

Alcohol, such as ethanol and isopropanol

No

Yes

Don’t Know

If Yes 

Ammonia

No

Yes

Don’t Know

If Yes 

Bleach or chlorine such as Clorox®

No

Yes

Don’t Know

If Yes 

Detergents

No

Yes

Don’t Know

If Yes 

Enzymatic cleaners such as Asepti-Zyme®, 3M Rapid Multi-Enzyme®

No

Yes

Don’t Know

If Yes 

Floor wax stripper

No

Yes

Don’t Know

If Yes 

Phenolics, such as 3M Phenolic Disinfectant 18®, WexCide®, MicroBakII®, Megacide®, Novigard®, Sporicidin®

No

Yes

Don’t Know

If Yes 

Quaternary ammonium compounds “Quats”, such as 3M Neutral Quat 23®, 3M HB Quat 25®, Sani-Cloth Plus®, Oasis®, Staphene®, BTC100®, BioQuat®, Sentinel®

No

Yes

Don’t Know

If Yes 

Days per week

Gloves Worn

Please write any other cleaning or disinfection chemicals or products you use for cleaning fixed surfaces, equipment, or instruments

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

1.

2.

3.

4.

5.

6.

20.2 On a typical day when you use cleaners or disinfectants on fixed surfaces, equipment, or instruments, how many times per day do you use these products?

Less than 1 time per day	1-3 times per day	4-10 times per day	More than 10 times per day

20.3 On a typical day when you use cleaners or disinfectants on fixed surfaces, equipment, or instruments, on average how many hours per day do you use these products?

Less than 1 hour per day	1-4 hours per day	More than 4 hours per day

20.4 On a typical day when you use cleaners or disinfectants on fixed surfaces, equipment, or instruments, do you use more sprays or more wipes, or do you use both equally often?

Select the ONE best answer.

Use more sprays than wipes

Use more wipes than sprays

Use sprays and wipes about equally

Not sure which I use more

20.5 What tasks do you perform when cleaning or disinfecting fixed surfaces, equipment, or instruments?

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 days per week, times per week, duration of task, and the type of gloves used.

Tasks

Do you perform this task?

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

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

No

Yes

If Yes 

__ __

_____ hrs min

Cleanup spills or blood

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Manually mix, refill, or empty cleaning or disinfecting products

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Clean bathrooms including toilet, sink, shower

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Spray then wipe glass, windows, mirrors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Polish wood furniture

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Polish stainless steel surfaces

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Spray deodorant/ disinfectant

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Mop floors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Clean instruments such as scissors, stethoscopes, and thermometers

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Clean equipment such as IV poles, carts, monitors, and computers

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Terminal cleaning of patient rooms

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Cleaning or disinfecting for MRSA, VRE or other drug resistant bacteria in patient rooms

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

End of shift cleaning of operating rooms, dialysis units or other patient care areas

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

20.6 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 20.6.1

20.6.1What 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 days per week, times per day, duration of task, and the type of gloves used.

Tasks

Do you perform this task?

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Strip floors

No

Yes

Don’t Know

__ __

_____ hrs min

Scrape floors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Prepare to buff floors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Buff floors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Wax floors

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

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: Have you worked in a medical or clinical laboratory? No Yes IF ‘NO’: GO TO QUESTION 22 IF ‘YES’: CONTINUE WITH QUESTION 21.1

21.1 What tasks and chemicals do you perform or use when you work in the medical or clinical laboratory?

IF YOU ANSWER ‘YES’ FOR A TASK OR CHEMICAL, please indicate how many days per week, times per day, duration of task, and the type of controls present.

Tasks and Chemical

Do you perform this task using this chemical?

Days per week

Times per day

Duration of Task

Controls

Less than 1

1

2

3

4

5

6

7

Tasks performed in a fume hood

Task performed using bench-top local exhaust ventilation?

Use formalin to fix grossed tissue and autopsy specimens

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

Uses stains and dyes such as haematoxylin and eosin stain

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

Use solvents such as xylene and toluene to fix tissue specimens and rinse stains

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

No

Yes

Don’t Know

No

Yes

Don’t Know

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, antiseptics, alcohols, or solvents, such as solutions to remove adhesives, iodine, hydrogen peroxide, super glue, bone cement, alcohols, alcohol preps, mineral spirits, or toluene, on patients? No Yes IF ‘NO’: GO TO QUESTION 23 IF ‘YES’: CONTINUE WITH QUESTION 22.1

22.2 What tasks do you perform when you apply or use chemicals, antiseptics, 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 days per week, times per day, duration of task, and the type of gloves used.

Tasks and Chemical

Do you perform this task using this chemical?

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Disinfect skin areas on patients prior to procedure using wipes, gauze or swabs with antiseptics such as alcohols, iodine, acetic acid to

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Clean and disinfect wounds using antiseptics such as, silver compounds, chlorhexidine, povidone iodine or cadexomer iodine

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Apply wound dressing such as polyurethane based hydrogel, hydrocolloid, or hydrocellular foam

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Use adhesive such as super glue, acrylates, bone cements, benzoin tincture such as 3M® Steri-Strip® for surgery, skin closure, bone repair, ostomy bags, and other applications

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Use adhesive removing solvents such as alcohols, acetone with wipes, gauze or swabs

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Apply synthetic fiberglass casts

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

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 that might include antibiotics, such as Tobramycin, Amikacin, Colistin, pentamidine, ribavirin, bronchodilators, anesthetics, and antitrypsin?

No Yes

IF ‘NO’: GO TO QUESTION 24

IF ‘YES’: CONTINUE WITH QUESTION 23.1

23.1 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 days per week, times per week, duration of task, and the type of gloves used when you administer aerosolized medications.

Tasks and

Do you perform this task or use this tool?

Days per week

Times per day

Duration of Task or Tool Use

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Administer aerosolized medications with a small volume nebulizer (SVN)

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Use continuous aerosol delivery system for bronchodilators and other medicines

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Administer aerosolized medications with a metered-dose inhaler (MDI)

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Administer aerosolized medications with a dry powder inhaler (DPI)

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

23.2 When you administer aerosolized medication do you use respiratory protection other than a surgical mask?

No Yes

IF ‘NO’: GO TO QUESTION 23.2.1

IF ‘YES’: CONTINUE WITH QUESTION 24

23.2.1 What percent of the time do you use any respirator, other than a surgical mask, when administering aerosolized medication?

About 25% of the time	About 50% of the time	About 75% of the time	100% of the time

23.2.2 What types of respirators do you use when administering aerosolized medication?

Particulate respirator such as an N95

Air purifying half mask

Air purifying full face piece

Powered air purifying

Other, please specify ____________________

Exposure to Chemicals used by Dental Assistants (Current Job)
24	Thinking about your current job and what you have done in this job in the last 12 months: Have you ever worked as a dental assistant?

No Yes

IF ‘NO’: GO TO QUESTION 25

IF ‘YES’: CONTINUE WITH QUESTION 24.1

24.1 What tasks do you do as a dental assistant?

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 days per week, times per week, duration of task, and the type of gloves used when you administer aerosolized medications.

Tasks

Do you perform this task?

Days per week

Times per day

Duration of Task

Gloves Worn

Less than 1

1

2

3

4

5

6

7

None

Nitrile

Latex or vinyl

Don’t know

Adjust, polish or repair dentures or use compunds such as methyl methacrylates, other acrylates, and epoxys

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Prepare amalgams such as Vertex Soft®, Villacryl Soft®, Molloplast B®,and Mollosil®

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Develop x-rays using film developing solutions

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Use adhesives to place dentures or attach braces

No

Yes

Don’t Know

If Yes 

__ __

_____ hrs min

Employment 5 Years Ago

25. Were you employed in health care 5 years ago? No Yes

IF ‘NO’: CONTINUE WITH QUESTION 25.1

IF ‘YES’: GO TO QUESTION 26

25.1 Please check the ONE box that best describes your employment status 5 years ago?

Employed outside of the healthcare industry

Disabled

On family leave

On extended sick leave

Retired

Student

Other, please specify: __________________________________

IF YOU CHECKED “Employed outside of healthcare industry” CONTINUE TO QUESTION 51.2. OTHERWISE GO TO QUESTION 40?

25.2 Please check the ONE box that best describes the type of industry your job was in 5 years ago.

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

Agriculture, forestry, and fishing

Construction trades

Health care and social assistance

Manufacturing

Mining

Oil and gas extraction

Public safety

Services, such as finance, real estate, education, hospitality, repair, or human resources

Transportation, warehousing, and utilities

Wholesale and retail trade

25.3 Please write in the title for the job you had 5 years ago. ______________________________

51.4 What did you do at the job you had 5 years ago?

25.5 What was the name of the company where you worked 5 years ago?

_________________________________________________________________________________________

26 Use the lists below to identify the 2-digit occupation code for the job you had in healthcare 5 years ago and the 2-digit facility 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.

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

26.2 In which unit did you work 5 years ago? __ __ Facility code

List of 2-digit occupation codes Please select single best code for the job you had 5 years ago and record above. 01: Medical instrument preparers or endoscopy technician 02: Environmental service worker, housekeeper, or cleaner 03: Lab technician, lab technologist, or assistant in a medical or clinical laboratory 04: Nursing assistant, nurse technician, nurse support assistant, patient care technician, patient support or orderly 05: Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (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 facility codes Please select single best code for the facility where you worked 5 years ago and record above. 01: Hospital 02: Nursing Home 03: Other, please specify _______________________________________ _______________________________________

26.3 Use the lists below to identify the 2-digit location code for where your job 5 years ago was located. If you had more than one job 5 years ago, record information for the job where you worked the most hours per week.
	26.3.1 Where is your work location? __ __ location code
	List of 2-digit location codes Please select single best code for the location where you worked 5 years ago and record above. 01: Patient care ward 02: Administration 03: Central supply 04: Dental 05: Dialysis 06: Ear, nose, and throat (ENT) 07: Education 08: Emergency room (ER) 09: Endoscopy 10: Float or multiple locations 11: General or internal medicine 12: Intensive care 13: Labor and delivery 14: Outpatient care 15 Pediatric 16: Psychiatric 17: Pulmonary 18: Surgery or operating room 19: Other unit, please specify _______________________ _______________________________________

27 How many hours per week did you work in the job you had 5 years ago? 28 What year did you begin that job? __ __ __ __ 29 What year did you stop working in that job? __ __ __ __ 30 Were you regularly exposed to vapors, gases, dust, or fumes in that job?	__ __ hours per week No Yes
31 Thinking about the job you had 5 years ago, did you sterilize or high-level disinfect medical instruments, including dental instruments and ventilator parts, in central supply or other locations such as endoscopy and bronchoscopy units, hemodialysis units, operating rooms, or other clinical settings? No Yes
32 Thinking about the job you had 5 years ago, did you clean or disinfect fixed surfaces, equipment, or instruments? Examples of fixed surfaces are: countertops, floors, beds, and bathrooms. Examples of equipment are: IV poles, monitors, carts, and computers. Examples of instruments are: blood pressure cuffs, and stethoscopes.	No Yes
33 Thinking about the job you had 5 years ago, did clean and wax floors using strippers and buffers?	No Yes
34 Thinking about the job you had 5 years ago, did you work in a medical or clinical laboratory?	No Yes
35 Thinking about the job you had 5 years ago, did you use chemicals, adhesives, antiseptics, alcohols, or solvents, such as solutions to remove adhesives, iodine, hydrogen peroxide, super glue, bone cement, alcohols, alcohol preps, mineral spirits, or toluene, on patients?	No Yes
36 Thinking about the job you had 5 years ago, did you administer aerosolized medications that might include antibiotics, such as Tobramycin, Amikacin, Colistin, pentamidine, ribavirin, bronchodilators, anesthetics, and antitrypsin?	No Yes
37 Thinking about the job you had 5 years ago, did you work as a dental assistant?	No Yes
38 Thinking about the job you had 5 years ago, did you observe any of the following in the building where you worked? 38.1 Water leakage or water damage indoors on walls, floors, or ceilings? 38.2 Visible mold growth (not on food) indoors on walls, floors, or ceilings? 38.3 Odor of mold or mildew (not from food)?	No Yes No Yes No Yes
39 Thinking about the job you had 5 years ago, were there renovations or construction at your job?	No Yes

Changing Jobs

40 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 41 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. _____________________________________________________________________________
	40.1 In which year did you change or leave this job or position? ___ ___ ___ ___
	40.2 Concerning the job or position you changed or left:
	40.2.1 What kind of job or position did you change or leave? __________________________________________________________
	40.2.2 Please check the ONE box that best describes what industry the job or position you changed or left was in? Agriculture, forestry, and fishing Construction trades Health care and social assistance Manufacturing Mining Oil and gas extraction Public safety Services, such as finance, real estate, education, hospitality, repair, or human resources Transportation, warehousing, and utilities Wholesale and retail trade
	40.2.3 What had you done in the job or position you changed or left? __________________________________________________________
	40.2.4 What exposure or activity affected your breathing in the job or position you changed or left? __________________________________________________________
	40.3 Concerning the job or position you went to:
	40.3.1 What kind of job or position did you go to? __________________________________________________________
	40.3.2 Please check the ONE box that best describes what industry the job or position you went to was in? Agriculture, forestry, and fishing Construction trades Health care and social assistance Manufacturing Mining Oil and gas extraction Public safety Services, such as finance, real estate, education, hospitality, repair, or human resources Transportation, warehousing, and utilities Wholesale and retail trade
	40.3.3 What did you do in this new job or position? __________________________________________________________
	40.3.4 What was the name of the company where you worked at this new job? ________________________________________________________________________________

Demographics

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

Year

42 What is your sex? Male Female

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

No Yes

IF ‘NO’: Go to Question 44	IF ‘YES’: 43.1 Which of the following best describes your Hispanic, Latino/a, or Spanish origin? (Mark only one)
	Mexican, Mexican American, or Chicano
	Puerto-Rican
	Cuban Another Hispanic, Latino, or Spanish origin
	If other, please specify: __________________________________________

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

White

Black or African American

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander – Specify: _________________________________________

45 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, vocational, or technical education

4 year college graduate (Bachelor’s degree)

Graduate or Medical

---- Thank you for completing the survey! ----