Employer screener

ATTACHMENT C

EMPLOYER SCREENER

(PHASES I AND II)

N

Form Approved OMB No. 0920-xxxx Exp. Date XX/XX/20XXXX/XX/20XX

IOSH Workforce Assessment

Employer Survey Establishment Screener (May 2010)

Hello, my name is __________, and I’m calling on behalf of the National Institute for Occupational Safety and Health, an agency of the U.S. Centers for Disease Control and Prevention.

Q1. Have I reached (SAMPLED ESTABLISHMENT)?

YES (PRIMARY NAME MATCH) 1 (Q4)

YES (SECONDARY NAME MATCH) 2 (Q4)

ESTABLISHMENT CHANGED NAME 3

NO, ANOTHER ESTABLISHMENT 4

RESIDENCE ONLY 5 (Q4)

Q2. What is the name of your business (or organization)?

[VERIFY SPELLING OF BUSINESS NAME.]

NAME: ______________________________________

RESIDENCE ONLY 5 (Q4)

Q3. In this (business/organization) the same as (SAMPLED ESTABLISHMENT)?

[IF NECESSARY: Do you consider it the same (business/organization)?]

YES 1

NO 2

[IF ESTABLISHMENT NAME CHANGED AND ESTABLISHMENT IS THE SAME AS SAMPLED ESTABLISHMENT (Q1 = 3 AND Q3 = 1) RECORD NAME]

NEW ESTABLISHMENT NAME: _____________________________________

Q4. Are you located at (SAMPLED ESTABLISHMENT ADDRESS)?

YES 1

NO 2

[IF THIS IS A RESIDENCE OR ORGANIZATION OTHER THAN SAMPLED

ESTABLISHMENT, ASK Q5. IF SAMPLED ESTABLISHMENT BUT DIFFERENT ADDRESS,

SKIP TO Q6. OTHERWISE, SKIP TO Q9]

Public reporting 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 compiling 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 current 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 (XXXXXX).

Q5. Do you know what happened to (NAME OF SAMPLED ESTABLISHMENT)?

YES, IT CLOSED/OUT OF BUSINESS 1 (END)

YES, IT MOVED 2 (Q8)

YES, SOMETHING ELSE 4 (Q8)

NO/DON’T KNOW 3 (END)

Q6. Does (SAMPLED ESTABLISHMENT) have an office at (SAMPLED ADDRESS)?

YES 1

NO 2 (Q8))

Q7. Can you give me the telephone number for (SAMPLED ESTABLISHMENT) for that location?

(______) ___________________ (END )

Q8. Do you know the phone number or address of (SAMPLED ESTABLISHMENT)?

[VERIFY PHONE NUMBER AND SPELLING OF ADDRESS.]

PHONE NUMBER: (_____)____________

ADDRESS: ________________________________________ (END)

Q9. I need to speak to someone who can who can tell us if there are any people at this location whose jobs specialize in worker safety and health. Can you give me the name and phone number of someone I can talk to about this (perhaps someone in your Human Resources department, or an office manager)?

(IF NECESSARY: We mean people whose jobs involve protecting workers from things such as workplace injuries, occupational diseases, exposure to harmful chemicals or radiation, or that help workers recover from such events. These could be safety professionals, industrial hygienists, occupational health nurses and physicians, ergonomists, health physicists, and so on.)

[VERIFY PHONE NUMBER AND SPELLING OF NAME]

NAME:_____________________________

PHONE NUMBER: (_____)____________ EXT.:____________

Q9a. Can you please connect me with this person?

YES 1

NO 2 (END)

Q10. (Hello, my name is __________, and I’m calling on behalf of the National Institute for Occupational Safety and Health, an agency of the U.S. Centers for Disease Control and Prevention. We are preparing for an important nationwide study regarding the occupational safety and health workforce.) Are there any people at this location, (SAMPLED STREET ADDRESS), whose jobs specialize in worker safety and health?

(IF NECESSARY: We mean people whose jobs involve protecting workers from things such as workplace injuries, occupational diseases, exposure to harmful chemicals or radiation, or that help workers recover from such events. These could be safety professionals, industrial hygienists, occupational health nurses and physicians, ergonomists, health physicists, and so on.)

YES 1

NO 2 (END)

Q11. We would like to send some information regarding this study to the most senior person whose job involves worker safety and health at this location. Could I please have the name, telephone number, and email address of this person?

(IF NECESSARY: We want to send this person a letter describing the study and asking him or her to participate by responding to a survey being done on the internet)

Q11a. [IF ONLY ONE NAME PROVIDED, ASK] Sometimes people who specialize in worker safety and health work in more than one department within a company. In order to get the most complete data possible for this location, is there another senior person we should contact for this study? Anyone else?

[VERIFY SPELLING OF NAME, PHONE NUMBER, AND EMAIL ADDRESS]

	PRIMARY CONTACT	SECONDARY CONTACTS
NAME
PHONE/EXT.
EMAIL

[Q12-Q12a WILL BE ASKED FOR BOTH PRIMARY AND SECONDARY CONTACT]

Q12. Is Mr/Mrs. (NAME) office located at (SAMPLED ESTABLISHMENT ADDRESS)?

YES 1 (END)

NO 2

Q12A. Could you please tell me where he/she is located?

[VERIFY SPELLING]

STREET ADDRESS:_____________________________

______________________________________________

CITY:________________ STATE:________ ZIP:_____________ (END)

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