Phase 1 Baseline Form

Attachment 7

Form Approved

OMB No. 0920-0843

Exp. Date 1/31/2013

Form Name: Phase I Baseline Form

Pilot Mine Baseline Form

Subject ID: ­­­­­­____________

DEMOGRAPHICS

1. What is your sex (please circle)?

1. Male

2. Female

2. How old are you (please enter)? __________________

3. What hand do you use to do most things (please circle)?

1. Right

2. Left

4. What is your height (please enter)?__________________

5. What is your weight (please enter)? __________________

6. What is your current job type (please enter)? ____________________________

7. How many total years of experience do you have in the mining industry (please enter)? __________________

8. How many years of experience do you have at this mine (please enter)? _______­­_

9. How many years of experience do you have in your current job (please enter)? _______­­________­­_

10. How many hours do you typically work in a week (please enter)? _______­­_____

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 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 (0920-0843).

11. Please show the kneepads you are currently using to the interviewer an, with their help, describe the following features (please circle all that apply)?

Outer Shell

1. Leather outer shell

2. Hard plastic outer shell

3. Soft plastic/rubber outer shell

4. Other (please specify) _________________________

Padding

1. Hard inner padding

2. Soft inner padding

3. Use second kneepad for additional padding (e.g. spider kneepads)

4. Other (please specify) _________________________

Type

5. Articulated (hinged)

6. Non-articulated

Straps

7. Rubber

8. Leather

9. Other (please specify) _________________________

12. How often are you on your knees per day (please circle)?

1. < 1 hour

2. 1-3 hours

3. 3-5 hours

4. >5 hours

13. Have you ever experienced a knee injury or knee pain (please circle)?

1. Yes (please specify) ______________________________

2. No

14. Have you ever had a knee infection (please circle)?

1. Yes

2. No

15. How do you take care of your knee infection (please circle)?

1. Not applicable

2. Antibiotic

3. Antiseptic cream

4. Lotion

5. Other (please specify) _____________________________________

16. Do you ever experience chafing or abrasion while wearing kneepads (please circle)?

1. Yes

2. No

17. How do you reduce friction to prevent chafing or abrasion injuries (please circle)?

1. Not applicable

2. Creams

3. Lotions

4. Salves

5. Vasoline

6. Clothing/other material (please specify) ___________________________

7. Other (please specify) _____________________________________

18. Do you have any ideas on equipment or aids other than kneepads that may help prevent knee injuries or discomfort (please write any information provided by the miner)?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL NOTES

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