Attch H-5 Early Exit Interview

Form Approved

OMB No. 0920-XXXX

Exp.Date: xx/xx/20xx

Attachment H-5:

Early Exit Interview

This interview will be administered to all participating employees that exit the study before the 2 year follow-up is completed. Public reporting burden of this collection of information is estimated to average 5 minutes per data collection, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information.

INSTRUCTIONS

READ TO RESPONDENT:

We are asking for your help in understanding how to better design research that is relevant to you and your work. Before we begin the interview there are a couple of important things I need to tell you.

PRIVATE and SECURE: Your answers will be protected to the extent possible under the Privacy Act.

ACCURACY: Your answer is important to us. Take your time and ask me if you are not sure what a question means. If there is any question you would prefer not to answer, just tell me and I will go on to the next question.

VOLUNTARY: Your participation is, of course, voluntary.

Do you have any questions before I start?

START TIME:____________________________

I understand that you are leaving the study.

1: What is your reason for leaving the study?

O Changed to a different job with the same company; O Changed to a different job with a different Company O Other reason (please specify)

2: Have you had any pain within the last 3 months in any of these body areas?

Low back- O Yes; O No;

If yes, how would you rate your level of NECK pain AT ITS WORST? No pain; Mild pain; Moderate pain; Severe pain; Very severe pain;

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)

Shoulders- O Yes; O No;

If yes, how would you rate your level of NECK pain AT ITS WORST? No pain; Mild pain; Moderate pain; Severe pain; Very severe pain;

Neck- O Yes; O No;

If yes, how would you rate your level of NECK pain AT ITS WORST? No pain; Mild pain; Moderate pain; Severe pain; Very severe pain;

Hand/ Wrist- O Yes; O No;

If yes, how would you rate your level of NECK pain AT ITS WORST? No pain; Mild pain; Moderate pain; Severe pain; Very severe pain;

Elbows/ Forearms- O Yes; O No;

If yes, how would you rate your level of NECK pain AT ITS WORST? No pain; Mild pain; Moderate pain; Severe pain; Very severe pain;

3: Is your changing jobs or leaving the study related to having pain in any of these body areas?

O Yes; O No; O Don’t know;

If yes, which body area?

Low back- O Yes; O

No; Shoulders- O Yes; O No;

Neck- O Yes; O No;

Hand/ Wrist- O Yes; O No;

Elbows/ Forearms- O Yes; O No;

4: How could we we encourage you to participate in future surveys? ____________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to answer these questions.