Survey - English

Attachment C: Survey Items – English Translation

Form Approved

OMB No. 0920-0572

Ex. Date 02/28/2015

Spanish Trench Safety CD-ROM

Public reporting burden of this collection of information is estimated to average 20 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333: ATTN: PRA (0920-0572)

Introduction

Thank you for agreeing to participate. Your participation in the research is voluntary. You can refuse to answer any questions and can stop participating at any time. There are no foreseeable risks to you from participating in this project and there is no direct benefit to you, except that your help may improve trench safety training in the future for construction workers. There will be no costs to you, other than your time involved. Do you have any questions? Let’s begin.

1. Behavioral Intentions

1. Do you plan on [do you remember ever] checking the trench for dangerous conditions before you enter[ed] it? (Yes, No, Not sure/don’t know, refused)

2. Do you plan on [ do you remember ever] talking to your supervisor about the risks present at the worksite? (Yes, No, Not sure/don’t know, refused)
   
   
   

3. Do you plan on [do you remember ever] entering a trench that was NOT inspected by the “competent” person? (Yes, No, Not sure/don’t know, refused)

4. Do you plan on [do you remember ever] entering a trench that you thought was unsafe? (Yes, No, Not sure/don’t know, refused)

5. Do you plan on [do you remember ever] expressing concerns to your coworkers about the dangers present at the worksite? (Yes, No, Not sure/don’t know, refused)

6. Do you remember ever feeling scared or worried about your safety when doing your job? (Yes, No, Not sure/don’t know, refused)
   
   

2. Attitudes
   
   

7. My coworkers believe that working in unsafe trenches is a problem at our job (Strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree).

8. I feel that working in unsafe trenches is a problem at my job (Strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree).

9. I am confident I can escape from a collapsing trench by getting out of the way in time. (Y/N)

10. How willing would you be to enter an unprotected trench for just a minute or two? (Very willing, somewhat willing, somewhat unwilling, very unwilling)
    
    

11. I feel as though I can make a difference regarding safety hazards at work (Y/N)

12. How willing would you be to talk about safety concerns with your coworkers? (Very willing, somewhat willing, somewhat unwilling, very unwilling)

13. My supervisor really doesn’t care about the safety of the employees. (Strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree)

14. How comfortable are you right now with talking to your supervisor about a safety concern on the job? (Very comfortable, somewhat comfortable, somewhat uncomfortable, very uncomfortable)
    
    

15. How comfortable are you right now with talking to your co-workers about safety concerns on the job? (Very comfortable, somewhat comfortable, somewhat uncomfortable, very uncomfortable)

3. Demographic Questions

16. Gender ( ) Male ( ) Female

17. What is the highest level of education you have completed?

___ 3 years or less

___ 4-6 years

___ 7-9 years (junior high school)

___ 10-12 years (high school or technical school)

___ Some college or technical school

___ Received four-year college degree

___ Some post graduate studies

___ Received advanced degree

___ Other: ______________________________

18. What is your current job title? What term would you use to describe your current profession?

_________________________________________________________________

19. Which of the following categories best describe your total, annual household income?

___ Under $20,000/year

___ $20,001 - $30,000/year

___ $30,001 - $40,000/year

___ $40,001 - $50,000/year

___ $50,001 - $60,000/year

___ $60,001 - $80,000/year

___ $80,001 - $100,000/year

___ Over $ 100,000/year

___ Don’t know/refused

20. About how often do you use a computer?

___ Several times a day

___ About once a day

___ 3-5 days a week

___ 1-2 days a week

___ Every few weeks

___ Less often

___ Never

___ Don’t know/refused