Phase I 1 month form

Attachment 8

Form Approved

OMB No. 0920-0843

Exp. Date 1/31/2013

Form Name: Phase I 1 month form

Subject ID: ­­­­­­____________

Time point in months (please circle): 1 3 6

DEMOGRAPHICS

1. Did you use your assigned kneepad for the entire time since our last visit (please circle; if “yes”, skip to question 3)?

1. Yes

2. No (please specify how long you did wear the kneepad: ______________)

2. What reasons did you have for not wearing your assigned kneepad (please circle all that apply; if the miner wore the assigned kneepad for less than 1 week, skip to question 37)?

1. Not applicable

2. Straps were uncomfortable

3. Would not stay in place

4. Was a tripping hazard

5. Caused discomfort at the leg

6. Caused discomfort at the knee

7. Caused discomfort at the thigh

8. Other (please specify) ________________________________________

3. What is your current job type (please enter)? _____________________________

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

5. How many days of leave have you had since our last visit (please enter)?_______________

Public reporting burden of this collection of information is estimated to average 25 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).

6. How many hours a week do you work most weeks (please enter)?_____________

7. How many hours a week have you typically worked since our last visit (please enter)?__________________

BODY PART DISCOMFORT

8. Point to the part of your body where you most often felt discomfort while performing your job over the past week (place an “x” over each region of the body identified by the miner)?

9. While wearing your current kneepad, how often have you felt any numbness, tingling, or lost feeling to your leg (please circle)?

1. Never

2. Occasionally

3. Frequently

4. Always

10. Have you experienced a knee injury or any knee pain at any time while wearing your current kneepad (please circle; describe if the answer is “Yes”)?

1. Yes (please describe: __________________________________________

_______________________________________________________________________________________________________________________)

2. No

11. Were there any postures that were uncomfortable or difficult because of the kneepad (show diagram to miner and let them identify posture(s); please circle all that apply)?

12. Were there any mine conditions that made working uncomfortable or difficult due to the kneepad (please circle all that apply)?

1. None

2. Uneven ground

3. Wetness

4. Mud

5. Rocky

6. Other (please specify) ___________________________

13. How comfortable are the straps (please circle)?

1. Very uncomfortable

2. Somewhat uncomfortable

3. Somewhat comfortable

4. Very comfortable

14. Does coal ever get trapped in the kneepad (please circle)?

1. Yes

2. No (skip to question 17)

15. How often does coal get trapped in the kneepad during your shift (please circle)?

1. Not applicable

2. 1-3 times

3. 4-6 times

4. 7-9 times

5. Other (please specify) ___________________________

16. Where in the kneepad does coal get trapped (please circle all that apply)?

1. Not applicable

2. Between the inner padding and outer shell

3. Between the knee and inner padding

4. Under the straps

5. Other (please specify) ___________________________

USABILITY

17. How difficult were the straps to put on (please circle)?

1. Difficult

2. Somewhat difficult

3. Somewhat easy

4. Easy

18. How difficult were the straps to take off (please circle)?

1. Difficult

2. Somewhat difficult

3. Somewhat easy

4. Easy

19. How difficult were the straps to adjust (please circle)?

1. Difficult

2. Somewhat difficult

3. Somewhat easy

4. Easy

20. How many times per shift did you make adjustments to the straps (please circle)?

1. 0-1 times

2. 2-3 times

3. 4-5 times

4. ≥ 6 times

21. When working in wet conditions, how water logged does your kneepad get by the end of your shift (please circle)?

1. Not water logged at all

2. Somewhat water logged

3. Extremely water logged

22. At the end of your shift, how sweaty are your pants where your kneepad rests? (please circle)?

1. Not sweaty

2. Somewhat sweaty

3. Extremely sweaty

4. Conditions too wet to determine

23. What kind of accidents, if any, has your current kneepad contributed to in the past (please circle all that apply)?

1. None

2. Accidently hit control lever

3. Tripped and fell while moving about the mine

4. Caught the kneepad on another object causing a trip or fall

5. Caught the kneepad on another object causing an uncomfortable twisting motion at the knee

6. Other (please specify) _________________________________________

EASE OF MOVEMENT

24. Does your current kneepad affect any of your movements?

1. Yes

2. No

25. What type of movements are affected by your current kneepad (please circle all that apply)?

1. Not applicable

2. Duck/stoop walking

3. Crawling

4. Switching between body positions

5. Other (please specify) ________________________

26. During your last shift, how well did your kneepad stay in place while moving about the mine (please circle)?

1. Not well at all

2. Somewhat well

3. Very well

DURABILITY

27. What features of the kneepad failed since your last interview (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to kneepad

4. Inner padding

5. Outer shell

6. Connection of inner padding to kneepad

7. Hinge (if applicable)

8. Other (please specify) ________________________

28. How durable were the following features of the kneepad (place an “x” under the appropriate category for each feature)?

29. Do you rotate between multiple pairs of your current kneepad type (please circle)?

1. Yes

2. No

30. How often do you rotate between multiple pairs of your current kneepads (please circle)?

1. Not applicable

2. Every day

3. Every week

4. Every month

5. Other (please specify) _______________

CLEANING

31. How often do you clean your kneepads (please circle)?

1. Never

2. Every day

3. Every week

4. Every month

5. Other (please specify) ________________

32. How do you clean your kneepads (please circle all that apply)?

1. Not applicable

2. Hose off with water

3. Spray with disinfectant

4. Spray with Bleach/Clorox and water solution (specify water to Bleach/Clorox ratio) ________________________

5. Briefly dip in Bleach/Clorox and water solution (specify water to Bleach/Clorox ratio) ________________________

6. Submerge for an extended period of time in Bleach/Clorox and water solution (specify water to Bleach/Clorox ratio) _____________________

7. Other (please specify) _________________________________________

CHANGES TO KNEEPAD

33. What features of your current kneepad do you like (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to kneepad

4. Inner padding

5. Outer shell

6. Connection of inner padding to kneepad

7. Hinge (if applicable)

8. Other (please specify) ________________________

34. What features of your current kneepad do you dislike (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to kneepad

4. Inner padding

5. Outer shell

6. Connection of inner padding to kneepad

7. Hinge (if applicable)

8. Other (please specify) ________________________

35. Did you modify any features of your current kneepad (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to kneepad

4. Inner padding

5. Outer shell

6. Connection of inner padding to kneepad

7. Hinge (if applicable)

8. Other (please specify) ________________________

36. If you modified your current kneepad, briefly explain any changes you made. (please write any information provided by the miner)._______________________

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BODY WEIGHT SUPPORT WORN AT THE ANKLE

37. How often did you wear the body weight support (please circle)?

1. Never

2. Occasionally

3. Often

4. Always

38. Why did you not wear the body weight support (please circle all that apply and continue with the form as long as the body weight support was worn at least occasionally; if the mine worker never wore the body weight support, this form is now complete as all other questions may be skipped)?

1. Not applicable

2. Straps were uncomfortable

3. Would not stay in place

4. Was a tripping hazard

5. Caused discomfort at the leg

6. Caused discomfort at the ankle/foot

7. Other (please specify) ________________________________________

39. Why did you wear the body weight support (please circle all that apply)?

1. Felt relief at the knee

2. Felt relief at the back

3. Enabled you to put more weight on your ankles/feet

4. Other (please specify) _________________________________________

40. Was the body weight support comfortable to wear (please circle)?

1. Not comfortable

2. Somewhat comfortable

3. Very comfortable

41. Was the body weight support useful (please circle)?

1. Not at all useful

2. Somewhat useful

3. Very useful

42. Did the body weight support increase your comfort compared to not using it (please circle)?

1. Not at all

2. Somewhat

3. A lot

43. Did you experience any discomfort due to the body weight support?

1. Yes

2. No

44. Where did you experience discomfort due to using the body weight support (please circle all that apply)?

1. Not applicable

2. Ankle

3. Knee

4. Toes

5. Buttocks

45. Was the body weight support water logged at the end of each shift (please circle)?

1. Not at all

2. Somewhat

3. Very

46. Did the body weight support move while you were working (please circle)?

1. Never

2. Occasionally

3. Frequently

4. Always

47. Did the body weight support make any movements difficult (please circle all that apply)?

1. None

2. Walking in a straight line

3. Switching directions while walking

4. Crawling in a straight line

5. Switching directions while crawling

6. Moving between different body positions

7. Other (please specify) _________________________________________

48. What features of the body weight support did you like (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to body weight support

4. Padding

5. Shape

6. Other (please specify) _________________________________________

49. What features of the body weight support did you dislike (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to body weight support

4. Padding

5. Shape

6. Other (please specify) _________________________________________

50. What features of the body weight support did you change or modify in any way (please circle all that apply)?

1. None

2. Straps

3. Connection of straps to body weight support

4. Padding

5. Shape

6. Other (please specify) _________________________________________

51. If you modified the body weight support, briefly explain any changes you made. (please write any information provided by the miner)?______________________

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52. What changes would you make to the kneepad to make it better suited for you, if any (please write any information provided by the miner)?___________________

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ADDITIONAL NOTES

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