Deepwater Horizon Responders - Paper

Form Approved
OMB No. 0920-0851

Gulf Coast Oil Spill Initial Survey

Date _____________
Name (Last, First, MI)

Date of birth

/
Cell phone (with Street address
area code)

Last four digits of social sec.

/
City

State

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

What has been your USUAL Job prior to the
Spill?
How many years have you been working at
your USUAL job?

On the Oil Spill, are you a:
Government worker

ZIP

Exp. Date 08/31/2010

Gender
Male
Female

Race/Ethnicity
White
Black
Hispanic
Asian
Other
Email address

Employer or volunteer organization on site

BP employee
Volunteer

Contractor
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 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:

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

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

Are you expecting to use personal
protective equipment to protect your
eyes (goggles or eyewear)?
Yes
No
Don’t Know
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 5 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 (0920-0851).