Demographic Questionnaire

Assessing and Evaluating Human Systems Integration Needs in Mining

Appendix S

Demographic Questionnaire

OMB: 0920-0981

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Appendix S: Demographic Questionnaire



































Form Approved

OMB No. 0920-xxxx

Expires xx/xx/20xx

Subject ID

Testing Date





/



/





Month Day Year

Gender








Male





Female


Anthropometry

Height




cm


Weight




.


kg


Current Job Title

Current Job Title:

Years in Current Job Title:



.


Years


Shift Length:



.


Hours


Shifts per Week:



.


Shift


Today’s Shift:

1st (Daylight)

2nd (Afternoon)

3rd (Cat-eye)

Other:__________


Shift Rotation:

None

1st & 2nd

1st, 2nd, & 3rd

Other:____________


Shift Rotation Schedule:

None

Every Week

Every Two Weeks

Other:____________


Mining Experience

Other Positions Worked:

Total Mining Experience:



.


Years


Number of Mines Worked:



Mines




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