Form No number No number Gulf Oil Spill Intake Survey

Form Approved

OMB No. 0920-XXX

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

Name (Last, First, MI) §

Date of birth

Last four digits of social sec.

Gender Male Female

Race/Ethnicity White Black Hispanic Asian Other

Cell phone (with area code)

Street address

City

State

ZIP

Email address

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).