Form 4 Self-Reported Upper Extremity Pain Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp.Date: xx/xx/20xx

Attachment H-2:

Self-reported Upper extremity pain questionnaire

(Quick DASH Questionnaire) (16 items)

This questionnaire will be completed by all participating employees at the start of the study and every 3 months for 2 years.

Public reporting burden for 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 the burden estimate to CDC/ASTDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).