Form 5 Self-Reported Specific Job Tasks and Safety Incidents Qu

Form Approved

OMB No. 0920-XXXX

Exp.Date: xx/xx/20xx

Attachment H-3:

Self-reported specific job tasks and safety incidents questionnaire (20 items)

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

PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.

Tasks	Never (0% of the time)	Occasional (1-33% of the time)	Frequent (34-66% of the time)	Regular. (67-100% of the time)
1: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? if never, please go to question 2
1a. How often was the new PHT-TLG used to handle objects over 100 lbs.?
1b. How often was another tool (such as regular hand truck) used to handle objects over 100 lbs.?
1c. How often did you use your body strength alone to handle large items?
2: Handling objects or stacked loads 50-100 lbs. (such as large boxes, shipping containers)? if never, please go to question 3
2a. How often was the new PHT-TLG used to handle objects 50-100 lbs.?
2b. How often was another tool (such as regular hand truck) used to handle objects 50-100 lbs.?
2c. How often did you use your body strength alone to handle objects 50-100 lbs.?
3 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). : Handling objects or stacked loads 25-50 lbs. (such as boxes, parts)?
4: Packing/ unpacking boxes or containers
5: Performing seated office work- computer use
6. Performing standing office work- sales or customer service
7: Driving a vehicle for work

PART B: Have you had any safety related incidents at work within the last 3 months? O Yes; O No; If yes, please mark below which type of incident occurred for each type of task.

Tasks	Type of safety incident
	Slip, trip or fall	Cuts or scratches	Strains or sprains	Other
1: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)?
2: Handling objects or stacked loads 50-100 lbs. (such as large boxes, shipping containers)?
3: Handling objects or stacked loads 25-50 lbs. (such as boxes, parts)?
4: Packing/ unpacking boxes or containers
5: Performing seated office work- computer use
6. Performing standing office work- sales or customer service
7: Driving a vehicle for work