Form No number No number Gulf Oil Spill Intake Survey

Gulf Oil Spill Worker Rostering Survey

NIOSH_Intake_Survey_051110

Gulf Coast Oil Spill Initial Survey

OMB: 0920-0851

Document [doc]
Download: doc | pdf

Form Approved

OMB No. 0920-XXX

Date _____________ Gulf Coast Oil Spill Initial Survey Exp. Date XX/XX/XXXX

Name (Last, First, MI)

Frame1 §

Date of birth

Frame2

Last four digits of social sec.

Frame3

Gender

Male

Female

Race/Ethnicity

White Black Hispanic

Asian Other

Cell phone (with area code)

Frame4

Street address

Frame5

City

Frame6

State

Frame7

ZIP

Frame8

Email address

Frame9

Name and number of contact who will know where you are in 6 months

Employer or volunteer organization on site


W

hat has been your USUAL Job prior to the Spill?


H

ow many years have you been working at your USUAL job?

On the Oil Spill, are you a: BP employee Contractor

Government worker Volunteer Don’t Know

Would you be willing to be contacted about participating in a possible

post-event survey? Yes No

Response Work (please be as specific as possible)


What will be your job or responsibilities?





Will your job tasks involve the potential of exposure to oil or oily substances?

Yes

No

Don’t Know

If yes, please describe the tasks:





What are your expected deployment location(s)?





How long are you planning on working on the oil spill?

less than 1 week to one week

1 week to 2 weeks

more than 2 weeks to one month

More than one month

As long as the work is available

I don’t know

What training have you received? (Check all that apply)

Module 1: BP HSE Basic Orientation

Module 2: Contractor Expectations

Module 3: Post-Emergency Spilled Oil Cleanup

First Responder Awareness

Annual refresher

First Responder Operations (8 hr)

Annual refresher

Hazardous Materials Technician (24 hr)

Annual refresher

HAZWOPER (24 hr)

Annual refresher

HAZWOPER (40 hr+)

Annual refresher

Other training, describe:




Are you expecting to use personal protective equipment to protect your skin?

Yes

No

Don’t Know

Are you expecting to use personal protective equipment to protect your eyes (goggles or eyewear)?

Yes

No

Don’t Know

Are you expecting to use respiratory protection?

Yes

No

Don’t Know

Have you been fit-tested for a respirator in the last year?

Yes

No

Don’t Know

Do you smoke?

Yes, number of cigarettes

per day:

No

Prefer not to answer

CDC recommends that adults be vaccinated for tetanus every 10 years. Have you had a tetanus vaccine within the past 10 years?

Yes

No

Don’t Know

Do you have other issues or concerns?


I have read and understand the Data Use and Disclosure sheet about who is collecting this information and how it will be used and that my participation is voluntary.

Signature ________________________________________________


Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).


File Typeapplication/msword
File TitleNatural Disaster Morbidity Report Form
Subjectsurveillance
AuthorCenters for Disease Control and Prevention (CDC)
Last Modified Bytqs7
File Modified2010-05-11
File Created2010-05-11

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