HHE Evaluation

Health Hazard Evaluations/Technical Assistance and Emerging Problems

Attachment F- updated

Health Hazard Evaluation Specific Questionnaire (Example)

OMB: 0920-0260

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ID# 001


Form Approved OMB No. 0920-0260

Expires 1/30/2012



U. S. Department of Health and Human Services

U. S. Public Health Service

Centers for Disease Control and Prevention








National Institute for Occupational Safety and Health

Health Hazard Evaluation 2010-0144

GE Aviation

Cincinnati, Ohio



This questionnaire is part of a National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation (HHE) of workplace health issues at GE Aviation in Cincinnati, Ohio. This questionnaire includes questions concerning health symptoms that you may have experienced or be experiencing, and some questions about your current job and work history. Participation in this HHE and completion of this questionnaire are voluntary. There is no penalty for choosing not to participate. However, full participation will better enable NIOSH to assess current health issues among employees at your workplace.


Please answer all questions to the best of your ability. If you don’t understand any of the following questions, please ask for assistance. All personal information from this questionnaire will be kept confidential according to federal law. Group summary results of this evaluation (without any personal identifying information) will be provided to employees, union representatives, and management in a final report after the evaluation is complete.



Name:____________________________________________________________________









Public reporting burden for this collection of information is estimated to average 30 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, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: P.A. (0920-0260). Do not send the completed form to this address.




  1. Today’s date: ______/______/2011

month / day


  1. What is your age?

_______ years


  1. What is your sex?

Female

Male


  1. In total, how long have you worked at GE Aviation?

_______ years

If less than 1 year, please enter the number of months worked: ____________months


  1. In which building do you currently work? If you work in both building 700 and 800, mark the one in which you work the most hours.

700

800

Other (specify: _____________________________)


  1. What is your current work area? (Check only one box.)

Seals

Large Parts

Shafts

IPE/Nozzles

Casing

Turbine Rear Frame

Turbine Mid Frame

Frames

Fins

Punch Press

Administrative Offices

Other (specify: _____________________________)


  1. What is your current job title? (Check only one box.)

Production Mechanic

Production Cell Machine Operator

Tool Maker

Tester

Maintenance

Administrative or Clerical

Other (specify: _____________________________)

  1. How long have you worked in your current job title at GE Aviation?

_______ years

If less than 1 year, please enter the number of months worked: ___________months


  1. How many hours per week do you usually work at GE Aviation?

_____ hours per week


  1. Do you usually work with coolant in your current job title at GE Aviation?

No  Yes 


If no, please answer the following question and then skip to Question #14

Have you ever worked with coolant at GE Aviation?

No  Yes 





  1. What kind of inserts do you use at work?

Carbide inserts only

Ceramic inserts only

Both carbide and ceramic inserts

I don’t work with inserts


  1. Do the machines you work with have a mist collector?

Yes, all have a mist collector

Yes, some have a mist collector

No, none have mist collectors


I

Do you feel that the mist collector is functioning properly to control the coolant mist?

Yes  No  If no, please list machine number(s) ______________

f yes:






  1. How is coolant supplied to the machines you work with:

Central coolant supply only

Each machine has its own coolant supply

Some have a central and some have their own coolant supply







  1. Do you wear gloves at work?

Yes, all the time

Yes, some of the time

No, never


If yes:

What type of glove(s) do you wear most often? (Check all that apply.)

Synthetic rubber (e.g., nitrile, neoprene, etc.)

Natural rubber or latex

Plastic (e.g., vinyl, PVC, polyethylene)

Cotton or cloth gloves

Leather

Other (describe: ________________________________)


What type of glove do you wear most often next to your skin? Please answer this question whether or not you wear one or two pairs of gloves at the same time. (Check only one box.)

Synthetic rubber (e.g., nitrile, neoprene, etc.)

Natural rubber or latex

Plastic (e.g., vinyl, PVC, polyethene)

Cotton gloves underneath rubber or plastic gloves

Cloth, other than cotton

Leather

Other (describe: ________________________________)























  1. On average, how many times per shift do you wash your hands with soap and water?

_____ times per shift


  1. On average, how many times per shift do you use hand-wipes to clean your hands?

_____ times per shift


  1. Do you use solvents such as mineral spirits, rubbing alcohol, or kerosene to clean your hands at work?

No  Yes 


If yes:

On average, how many times per shift do you clean your hands with solvents?

____ times per shift







  1. Do you apply moisturizing lotion to your hands or arms at work?

No  Yes 


If yes:

On average, how many times per shift do you apply moisturizing lotion?

____ times per shift





Barrier creams are used to prevent chemicals from penetrating the skin.



  1. Do you apply barrier cream at work?

No  Yes 


If yes:

On average, how many times per shift do you apply barrier cream?

_____ times per shift






  1. Outside of your job at this facility, have you worked with any of the following on a regular basis in the past 12 months? (Check all that apply.)

Hydraulic or engine oils, lubricants or oily metal parts

Solvents (any type)

Paints, primers, or glaze

Industrial strength cleaning agents

Glues, adhesives, tape, etc.

Sealants or caulks

Ceramic, plaster, or cement

Pesticides, herbicides, or fertilizers

Wood

Other (specify :_____________________________________)

I haven’t worked with any of these in the past 12 months


  1. Have you ever had an itchy rash that comes and goes for at least 6 months, and at some time has affected skin creases? (by creases we mean inside of elbows, behind the knees, fronts of ankles, around the neck, ears, or eyes)

No  Yes 





For questions 22-28, please use the following definition:

Dermatitis is a skin irritation or rash with red, dry skin that can have tiny bumps or blisters, flaking, cracks, or crusts. The skin often itches, burns, or stings.





  1. Have you had dermatitis at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?

On your hands or fingers? No * Yes **

On your wrists or forearms? No * Yes **

On your face or neck? No * Yes **


*If no to all three items in question 22, go to question 29.

**If yes to any, please continue with question 23.


23. Do you have dermatitis now?

No  Yes 


If no:

When you were away from work for more than 5 days was your dermatitis:

Better

The same

Worse









If yes:

When you are away from work for more than 5 days is your dermatitis:

Better

The same

Worse









24. In the past 12 months, have you changed glove type because of your dermatitis?

No  Yes 


I

What type of glove(s) did you stop wearing because of your dermatitis?

___________________________________________________________



f yes:




25. In the past 12 months, did you begin to wear gloves because of your dermatitis?

No  Yes 



26. Did you have to change jobs due to your dermatitis?

No  Yes 


If yes:

After changing jobs was your dermatitis:

Better

The same

Worse









27. What do you think was the cause of your dermatitis?

_____________________________________________________________________________


28. Have you seen a doctor for your dermatitis at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?

No  Yes 


If yes:

Did the doctor do any of the following tests to diagnose your dermatitis? Check all that apply.

Blood test

Skin patch test

Skin prick, puncture, or scratch test

Other (specify: ___________________________________)

No tests were done to make the diagnosis


What did the doctor say that you had? Check all that apply.

Allergic contact dermatitis (Allergic to what? ____________________)

Irritant contact dermatitis

Other (specify: ____________________________________)

Don’t know


Did the doctor say the dermatitis was related to your job?

No  Yes  Maybe 

























  1. In what season do you have the most problems with dermatitis? (Check only one box.)

Winter

Spring

Summer

Fall

No seasonal difference


All employees continue with Question 29




  1. Have you had wheezing or whistling in your chest at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?

No  Yes 


If yes:

Have you been at all breathless when the wheezing or whistling noise was present?

No  Yes 


Have you had this wheezing or whistling when you did not have a cold?

No  Yes 


When you are away from work on days off or vacation, is this wheezing or whistling:

Better

The same

Worse

















  1. Have you been woken up with a feeling of tightness in your chest at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?

No  Yes 


If yes:

When you are away from work on days off or on vacation, are your episodes of chest tightness:

Less often

The same

More often









  1. Have you ever had asthma?

No  Yes 



If yes:

Did your asthma start after you began working in your current job title?

No  Yes 


Have you had an attack of asthma in the last 12 months (or since beginning your current position if in that position less than 12 months)?

No  Yes 

If yes,










When you are away from work on days off or on vacation, are your attacks of asthma:

Less often

The same

More often













  1. Are you currently taking any medicine (including inhalers or pumps, aerosols, or tablets) for asthma?

No  Yes 


If yes:

When you are away from work on days off or on vacation, do you take the medicine for asthma:

Less often

The same

More often












  1. Have you ever had “hay fever” or other symptoms of nasal allergy?

No  Yes 




  1. In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had a problem with sneezing, runny nose, or blocked nose when you did not have a cold or flu?

No  Yes 


I

When you are away from work on days off or on vacation, is this problem:

Better

The same

Worse


In the last 12 months, has this nose problem been accompanied by itchy, watery eyes?

No  Yes 

f yes:










  1. In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had more than one episode of illness with at least 2 of the following symptoms?

Cough

Wheeze

Shortness of breath

Chest tightness


No  Yes 


If yes:

Were these episodes combined with fever or weight loss?

No  Yes 






  1. In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had pneumonia or chest flu?

No  Yes 


If yes:

How many times have you had pneumonia or chest flu in the last 12 months (or since beginning your current position if in that position less than 12 months)?

__________times







  1. What is your smoking history?

Never smoked means fewer than 20 packs of cigarettes in a lifetime or less than 1 cigarette a day for 1 year.




Never smoked

Former smoker

Current smoker



Thank you for your participation!

21


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