2015 NHIS Occupational Health Supplement and Cancer Control Supplement

Attachment 1- 2015 NHIS Occupational Health Supplement

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 55 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 Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

**ASD.060_00.00/WRKCOR

What is your working status?

* Read answer categories.

1 Working for pay at a job or business

2 With a job or business but not at work

3 Looking for work

4 Working, but not for pay, at a family-owned job or business

5 Not working at a job or business and not looking for work

7 Refused

9 Don't know

Skip Instructions: <1,4> go to WHOWRK; <2,5> go to WHYNOWK2; <3,R,D> go to EVERWRK

**ASD.065_00.00/WHYNOWK2

What is the main reason you did not work last week?

01 Taking care of house or family

02 Going to school

03 Retired

04 On a planned vacation from work

05 On family or maternity leave

06 Temporarily unable to work for health reasons

07 Have job or contract and off-season

08 On layoff

09 Disabled

10 Other

97 Refused

99 Don't know

Skip Instructions: <1-10,R,D> if WRKCOR = 2 then go to WHOWRK; else go to EVERWRK

**ASD.066_00.00/EVERWRK

Have you ever held a job or worked at a business?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: <1> go to WHOWRK; <2,R,D> go to next section

**ASD.070_00.00/WHOWRK

Interviewer: Choose appropriate fill.

(Fill1: For whom did you work at your MAIN job or business? (Name of company, business, organization or employer))

(Fill2: Thinking about the job you held the longest, for whom did you work? (Name of company, business, organization or employer))

(Fill3: Thinking about the job you held most recently, for whom did you work? (Name of company, business, organization or employer))

Verbatim Verbatim response

7 Refused

9 Don't know

**ASD.080_00.00/KINDIND

What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

Verbatim Verbatim response

7 Refused

9 Don't know

**ASD.090_00.00/KINDWRK

What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)

Verbatim Verbatim response

7 Refused

9 Don't know

**ASD.100_00.00/IMPACT

What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)

Verbatim Verbatim response

7 Refused

9 Don't know

ASD.105_00.010/SUPERVIS

* Ask if necessary.

Did you supervise other employees as part of your job?

1 Yes

2 No

7 Refused

9 Don't know

**ASD.110_00.00/WRKCAT

[If WRKCOR in(1,2,4)]

which of these best describes your current job or work situation?

[Else if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65)]

which of these best describes the job you held for the longest time?

[Else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

which of these best describes the job you held most recently?

* Read answer choices if necessary.

1 Employee of a PRIVATE company for wages

2 A FEDERAL government employee

3 A STATE government employee

4 A LOCAL government employee

5 Self-employed in OWN business, professional practice or farm

6 Working WITHOUT PAY in a family-owned business or farm

7 Refused

9 Don't know

Skip Instructions: <1-4,6,R,D> go to LOCALLNR; <5> go to BUSINC

**ASD.112_00.00/BUSINC

Is this business incorporated?

1 Yes

2 No

7 Refused

9 Don't know

**ASD.120_00.000/LOCALLNR

Thinking about

[If WRKCOR in(1,2,4)]

this MAIN job or business

[else if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65)]

your last week at the job you held the longest

[else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

your last week at the job you held most recently

how many people (Fill4:work/Fill5: worked) at this location? Please include yourself.

* "People" includes both FULL- and PART-time employees; "location" refers to the street address of the workplace.

01 1 employee

02 2-9 employees

03 10-24 employees

04 25-49 employees

05 50-99 employees

06 100-249 employees

07 250-499 employees

08 500-999 employees

09 1000 employees or more

97 Refused

99 Don't know

**ASD.140_01.00/WRKLONGN

1 of 2

About how long

[If WRKCOR in(1,2,4)]

have you worked at this MAIN job or business?

[else if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65)]

did you work at the job you held the longest?

[else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

did you work at the job you held most recently?

001-365 1-365

997 Refused

999 Don't know

Skip Instructions: <1-365> go to WRKLONGT;

<D,R> if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65) then go to HOURPD; else if

(EVERWRK=1 and WHYNOWK2 in (1,2,4-10,R,D) and AGE < 65)

**ASD.140_02.00/WRKLONGT

2 of 2

* Enter time period.

1 Day(s)

2 Week(s)

3 Month(s)

4 Year(s)

Skip Instructions: <4> if WRKLONGN > AGE then go to ERR_WRKLONGT

<1-4> if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65) then go to HOURPD;

else if (EVERWRK=1 and WHYNOWK2 in(1,2,4-10,R,D) and AGE < 65) or

(WRKCOR in(1,2,4)) then go to WRKLONGH

**ASD.146_00.00/WRKLONGH

[If WRKCOR in(1,2,4)]

Is this MAIN job or business the job you have held for the longest?

[else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

Was your most recently held job also the job you held the longest?

1 Yes

2 No

7 Refused

9 Don't know

**ASD.150_00.00/HOURPD

[If WRKCOR in(1,2,4)]

Are you paid by the hour at this MAIN job or business?

[else if EVERWRK=1 and (WHYNOWK2= 03 or AGE >= 65)]

Were you paid by the hour on the job you held the longest?

[else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

Were you paid by the hour on the job you held most recently?

1 Yes

2 No

7 Refused

9 Don't know

**ASD.160_00.00/PDSICK

[If WRKCOR in(1,2,4)]

Do you have paid sick leave on this MAIN job or business?

[else if EVERWRK=1 and (WHYNOWK2=03 or AGE >= 65)]

Did you ever have paid sick leave on the job you held the longest?

[else if EVERWRK=1 and WHYNOWK2 ne 03 and AGE < 65]

Did you ever have paid sick leave on the job you held most recently?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: if WRKCOR in(1,2,4) then go to ONEJOB; else if WRKCOR in(3,5) then go to WRKLYR2; else if WRKCOR in(R,D) then go to next section

**ASD.170_00.00/ONEJOB

Do you have more than one job or business?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: go to next section

**ASD.210_00.00/WRKLYR2

Although you did not work last week, did you have a job or business at any time in the PAST 12 MONTHS?

0 Had job last week

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If WRKCOR in(1,2,4) and WRKLONGH=2 then go to WHOWRKLH; else go to

WRKARRNG

Longest-held (Usual) Job

ASD.220_00.010/WHOWRKLH

Thinking of ALL the jobs or businesses you have ever had, including work done in the Armed Forces, for whom did you work the longest? (Name of company, business, organization or employer)

Verbatim Verbatim response

7 Refused

9 Don’t know

ASD.220_00.020/KINDINLH

What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

Verbatim Verbatim response

7 Refused

9 Don’t know

ASD.220_00.030/KINDWKLH

What kind of work were you doing? (For example: farming, mail clerk, computer specialist)

Verbatim Verbatim response

7 Refused

9 Don’t know

ASD.220_00.040/IMPACTLH

What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press)

Verbatim Verbatim response

7 Refused

9 Don’t know

ASD.220_00.050/WRKCATLH

Which of these best describes the job or business you held for the longest time?

1 An employee of a PRIVATE company, business, or individual for wages, salary, or commission

2 A FEDERAL government employee

3 A STATE government employee

4 A LOCAL government employee

5 Self-employed in OWN business, professional practice or farm

6 Working WITHOUT PAY in family-owned business or farm

7 Refused

9 Don’t know

ASD.220_00.060/WRKLGLHN

About how long did you work at the job or business you held the longest?

* Enter number.

_____________

997 Refused

999 Don’t know

Supplemental Work Organization Questions

ASD.220_00.080/ WRKARRNG

The next few questions refer to [fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]. Which of the following best describes your work arrangement?

* Read answer categories.

1 You work as an independent contractor, independent consultant, or freelance worker

2 You are on-call, and work only when called to work

3 You are paid by a temporary agency

4 You work for a contractor who provides workers and services to others under contract

5 You are a regular, permanent employee (standard work arrangement)

6 Other

7 Refused

9 Don’t know

ASD.220_00.090/ WRKSCHED

Which of the following best describes the hours you usually work?

* Read answer categories.

1 A regular daytime schedule

2 A regular evening shift

3 A regular night shift

4 A rotating shift in which the schedule changes periodically from day to evenings to night

5 A split shift that consists of two distinct periods each day

6 Some other schedule not mentioned

7 Refused

9 Don’t know

Skip Instructions: <1-3> go to TIMESTR1; <4-6,R,D> go to SCHEDCON

ASD.220_01.095/TIMESTR1

1 of 2

What time of day do you usually start work at this job?

* Enter time in HH:MM format.

_____ Time

97 Refused

99 Don’t know

Skip Instructions: <R,D> go to SCHEDCON; else go to TIMESTR2

ASD.220_02.095/TIMESTR2

2 of 2

* Enter ‘1’ for AM or ‘2’ for PM.

1 AM

2 PM

7 Refused

9 Don’t know

Skip Instructions: <1,2> go to TIMEFIN1; <R,D> go to SCHEDCON

ASD.220_01.095/TIMEFIN1

1 of 2

What time of day do you usually end work at this job?

* Enter time in HH:MM format.

_____ Time

97 Refused

99 Don’t know

Skip Instructions: <R,D> go to SCHEDCON; else go to TIMEFIN2

ASD.220_02.095/TIMEFIN2

2 of 2

* Enter ‘1’ for AM or ‘2’ for PM.

1 AM

2 PM

7 Refused

9 Don’t know

ASD.220_00.100/SCHEDCON

Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statement. “I have control over my work schedule.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

Exposures

Psychosocial Exposures/Work Environment

ASD.220_00.110/WORUNEMP

Now I’m going to read two statements that may or may not apply to [fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]. Please tell me whether you strongly agree, agree, disagree, or strongly disagree with each of these statements.

”I am worried about becoming unemployed.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

ASD.220_00.120/ WORKWFAM

Please tell me whether you completely agree, agree, disagree, or completely disagree with each of these statements.

“It is easy for me to combine work with family responsibilities.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

ASD.220_00.130/HARASSED

Again, think about [fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job].

DURING THE PAST 12 MONTHS, were you threatened, bullied or harassed by anyone while you were on the job?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to HARASFRQ; <2,R,D> go to SAFCLIMT

ASD.220_00.135/HARASFRQ

DURING THE PAST 12 MONTHS, how often were you threatened, bullied or harassed by anyone while you were on the job? Would you say seldom, sometimes, or often?

1 Seldom

2 Sometimes

3 Often

7 Refused

9 Don’t know

ASD.220_00.140/SAFCLIMT

Again, the next four questions are about [fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]. Please tell me whether you strongly agree, agree, disagree, or strongly disagree with each of these statements.

“The health and safety of workers is a high priority with management where I work.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

ASD.220_00.150/JOBDMAND

Please tell me whether you strongly agree, agree, disagree, or strongly disagree with each of these statements.

“I have too much work to do everything well.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

ASD.220_00.160/JOBCNTRL

Please tell me whether you strongly agree, agree, disagree, or strongly disagree with each of these statements.

“My job allows me to make a lot of decisions on my own.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

ASD.220_00.170/JOBSPPRT

Please tell me whether you strongly agree, agree, disagree, or strongly disagree with each of these statements.

“I can count on my supervisor or manager for support when I need it.”

1 Strongly agree

2 Agree

3 Disagree

4 Strongly disagree

7 Refused

9 Don’t know

General Exposures

ASD.220_00.180/EXERTION

Again, continue thinking about [fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]. How often does your job involve repeated lifting, pushing, pulling, or bending? Never, seldom, sometimes, often, or always?

1 Never

2 Seldom

3 Sometimes

4 Often

5 Always

7 Refused

9 Don’t know

ASD.220_00.190/HANDMOVE

How often does your job involve repetitive or forceful hand movements? Never, seldom, sometimes, often, or always?

1 Never

2 Seldom

3 Sometimes

4 Often

5 Always

7 Refused

9 Don’t know

ASD.220_00.200/ SMOKEXP

DURING THE PAST 12 MONTHS, were you regularly exposed to tobacco smoke from other people at work twice a week or more?

1 Yes

2 No

7 Refused

9 Don’t know

Workplace Health Promotion

ASD.220_00.210/HLTHPROM

In the past year, were health promotion programs made available to you by your employer? Examples of health promotion programs include education about weight management, smoking cessation, screening for high blood pressure, high cholesterol, or other health risks, and onsite fitness facilities or discounted gym memberships.

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to HPROMPAR; <2,R,D> go to next section

ASD.220_00.220/HPROMPAR

How often did you participate in any of these activities in the past year?

1 Never

2 Seldom

3 Sometimes

4 Often

7 Refused

9 Don’t know

Conditions

Joint (Shoulder) Pain

**ACN.250_00.000/JNTSYMP

The next questions refer to your joints. Please do NOT include the back or neck. DURING THE PAST 30 DAYS, have you had any symptoms of pain, aching, or stiffness in or around a joint?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to JMTHP; <2,R,D> go to SHP12M

**ACN.260_02.000/JMTHP

Which joints are affected?

* Enter all that apply, separate with commas.

01 Shoulder-right

02 Shoulder-left

03 Elbow-right

04 Elbow-left

05 Hip-right

06 Hip-left

07 Wrist-right

08 Wrist-left

09 Knee-right

10 Knee-left

11 Ankle-right

12 Ankle-left

13 Toes-right

14 Toes-left

15 Fingers/thumb-right

16 Fingers/thumb-left

17 Other joint not listed

97 Refused

99 Don't know

**ACN.270_00.000/JNTCHR

Did your joint symptoms FIRST begin more than 3 months ago?

1 Yes

2 No

7 Refused

9 Don't know

**ACN.280_00.000/JNTHP

Have you EVER seen a doctor or other health professional for these joint symptoms?

1 Yes

2 No

7 Refused

9 Don't know

ACN.285_00.005/SHP12M

DURING THE PAST 12 MONTHS did you have shoulder pain that lasted for a week or more?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instruction: <1> go to SHPWRKEL; <2,R,D> go to next section

ACN.285_00.010/SHPWRKEL

Have you been told by a doctor or other health professional that your shoulder pain was probably work-related?

1 Yes

2 No

7 Refused

9 Don’t know

ACN.285_00.020/SHPCBJOB

Do you think your shoulder pain was caused by any job you ever had?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to SHPCJOB; <2,R,D> go to SHPWKDAY

ACN.285_00.030/SHPCJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to SHPWKDAY; <2> if WRKLONGH=2, go to SHPLHJOB; else go to SHPWHOWK

ACN.285_00.040/SHPLHJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/the job you held the longest]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to SHPWKDAY; else go to SHPWHOWK

ACN.285_00.050/SHPWHOWK

For whom did you work when you developed shoulder pain? (Name of company, business, organization or employer)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.285_00.060/SHPKIND

What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.285_00.070/SHPKWRK

What kind of work were you doing? (For example: farming, mail clerk, computer specialist)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.285_00.080/SHPIMPAC

What were your most important activities on this job or business? (For example: sell cars, keeps account books, operates printing press)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.285_00.120/SHPWKDAY

DURING THE PAST 12 MONTHS, how many full days did you miss from work because of your shoulder pain?

* Enter ‘0’ for None.

____________ # days

97 Refused

99 Don’t know

ACN.285_00.130/SHPCHJOB

DURING THE PAST 12 MONTHS, did you stop working, change jobs, or make a major change in your work activities, such as taking on lighter duties, because of your shoulder pain?

1 Yes

2 No

7 Refused

9 Don’t know

Carpal Tunnel Syndrome

ACN.296_00.010/CTSEVER

Have you EVER been told by a doctor or other health professional that you have a condition affecting the wrist and hand called carpal tunnel syndrome?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to CTSYR; <2,R,D> go to PAINECK

ACN.296_00.020/CTSYR

DURING THE PAST 12 MONTHS have you had carpal tunnel syndrome?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to CTSWKREL; <2,R,D> go to PAINECK

ACN.297_00.010/CTSWKREL

Have you been told by a doctor or other health professional that your carpal tunnel syndrome was probably work-related?

1 Yes

2 No

7 Refused

9 Don’t know

ASD.297_00.020/CTSCBJOB

Do you think your carpal tunnel syndrome was caused by any job you ever had?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to CTSCJOB; <2,R,D> go to CTSWKDAY

ACN.297_00.030/CTSCJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to CTSWKDAY; <2> if WRKLONGH=2, then go to CTSLHJOB; else go to CTSWHOWK

ACN.297_00.040/ CTSLHJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/the job you held the longest]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to CTSWKDAY; <2> go to CTSWHOWK

ACN.297_00.050/CTSWHOWK

For whom did you work when you developed carpal tunnel syndrome? (Name of company, business, organization or employer)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.297_00.060/CTSKIND

What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.297_00.070/CTSKWRK

What kind of work were you doing? (For example: farming, mail clerk, computer specialist)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.297_00.080/CTSIMPAC

What were your most important activities on this job or business? (For example: sell cars, keeps account books, operates printing press)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.297_00.120/CTSWKDAY

DURING THE PAST 12 MONTHS, how many full days did you miss from work because of your carpal tunnel syndrome?

* Enter ‘0’ for None.

____________ # days

97 Refused

99 Don’t know

ACN.297_00.130/CTSCHJOB

DURING THE PAST 12 MONTHS, did you stop working, change jobs, or make a major change in your work activities, such as taking on lighter duties, because of your carpal tunnel syndrome?

1 Yes

2 No

7 Refused

9 Don’t know

Low Back Pain

**ACN.300_00.000/PAINECK

The following questions are about pain you may have experienced in the PAST THREE MONTHS. Please refer to pain that LASTED A WHOLE DAY OR MORE. Do not report aches and pains that are fleeting or minor.

DURING THE PAST THREE MONTHS, did you have

... Neck pain?

1 Yes

2 No

7 Refused

9 Don't know

**ACN.310_00.000/PAINLB

DURING THE PAST THREE MONTHS, did you have

... Low back pain?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: <1> [go to PAINLEG] <2,R,D> [go to LBP12M]

**ACN.320_00.000/PAINLEG

Did this pain spread down either leg to areas below the knees?

1 Yes

2 No

7 Refused

9 Don't know

ACN.325_00.005/LBP12M

DURING THE PAST 12 MONTHS did you have low back pain that lasted for a week or more?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instruction: <1> go to LBPWKREL; <2,R,D> end interview

ACN.325_00.010/LBPWKREL

Have you been told by a doctor or other health professional that your low back pain was probably work-related?

1 Yes

2 No

7 Refused

9 Don’t know

ACN.325_00.020/LBPCBJOB

Do you think your low back pain was caused by any job you ever had?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to LBPCJOB; <2,R,D> go to LBPWCCLM

ACN.325_00.030/LBPCJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/your current, MAIN job]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to LBPWCCLM; <2> if WRKLONGH=2, then go to LBPLHJOB; else go to LBPWHOWK

ACN.325_00.040/LBPLHJOB

Was this…

[fill: your job as a (JOB DESCRIPTION) with (EMPLOYER NAME)/the job you held the longest]?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1,R,D> go to LBPWKDAY; <2> go to LBPWHOWK

ACN.325_00.050/LBPWHOWK

For whom did you work when you developed low back pain? (Name of company, business, organization or employer)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.325_00.060/LBPKIND

What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.325_00.070/LBPKWRK

What kind of work were you doing? (For example: farming, mail clerk, computer specialist)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.325_00.080/LBPIMPAC

What were your most important activities on this job or business? (For example: sell cars, keeps account books, operates printing press)

Verbatim Verbatim response

7 Refused

9 Don’t know

ACN.325_00.100/LBPWCCLM

Have you ever filed a workers’ compensation claim for your low back pain?

1 Yes

2 No

7 Refused

9 Don’t know

Skip Instructions: <1> go to LBPWCBEN; <2,R,D> go to LBPWKDAY

ACN.325_00.110/LBPWCBEN

Have you ever received workers’ compensation benefits for your low back pain?

1 Yes

2 No

7 Refused

9 Don’t know

ACN.325_00.120/LBPWKDAY

DURING THE PAST 12 MONTHS, how many full days did you miss from work because of your low back pain?

* Enter ‘0’ for None.

____________ # days

97 Refused

99 Don’t know

ACN.325_00.130/LBPCHJOB

DURING THE PAST 12 MONTHS, did you stop working, change jobs, or make a major change in your work activities, such as taking on lighter duties, because of your low back pain?

1 Yes

2 No

7 Refused

9 Don’t know

50