Indium Facility Questionnaire

Form Approved

No. 0920-xxxx

Exp. Date xx/xx/20xx

Attachment C

INDIUM FACILITY QUESTIONNAIRE

Today’s Date: __ __ / __ __ / __ __ __ __

(Month) (Day) (Year)

Section I: Identification and Demographic Information

Your Name:_____________________________ ____________________________ ___

(Last name) (First name) (MI)

Your Mailing Address:

_______________________________________________________________________

(Number, Street, and/or Rural Route)

___________________________________ ______ ______________

(City) (State) (Zip Code)

Your Home Telephone Number: ( ) _______ - __________

Cell phone ( ) _______ - __________

If you move, is there someone who would know how to contact you?

Contact’s Name:_________________________ ____________________________ ___

(Last name) (First name) (MI)

Contact’s Relationship to you:____________________

Contact’s Mailing Address:

_______________________________________________________________________

(Number, Street, and/or Rural Route)

___________________________________ ______ ______________

(City) (State) (Zip Code)

Contact’s Telephone Number: ( ) _______ - __________

Cell phone ( ) _______ - __________

1. Date of Birth: __ __ / __ __ / __ __ __ __

(Month) (Day) (Year)

2. Sex: 1.____ Male 2. ____ Female

2. What is your ethnicity?

1. Hispanic or Latino ____

0. Not Hispanic or Latino___

4. Choose one or more of the following categories to describe your race:

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

Section II. Health Information

These questions pertain mainly to your chest. Please answer Yes or No if possible. If you are in doubt about whether your answer is Yes or No, answer No.

5a. Do you usually have a cough? 1. Yes ___ 0. No ___

(Count a cough with first smoke or on first going
out-of-doors. Exclude clearing of throat.)

IF YES:

5b. When did this cough start? ______ Month _____Year

5c. Do you usually cough on most days for
3 consecutive months or more during the year? 1. Yes ___ 0. No ___

6a. Do you usually bring up phlegm from your chest? 1. Yes ___ 0. No ___

(Count phlegm with the first smoke or on first going out-of-doors.
Exclude phlegm from the nose. Count swallowed phlegm)

IF YES:

6b. When did this trouble with phlegm start? ______ Month _____Year

7a. Are you troubled by shortness of breath when

hurrying on level ground or walking up a slight hill? 1. Yes ___ 0. No ___

IF YES:

7b. Do you have to walk slower than people of your

age on level ground because of breathlessness? 1. Yes ___ 0. No ___

7c. Do you ever have to stop for breath when walking

at your own pace on level ground? 1. Yes ___ 0. No ___

7d. When did this shortness of breath start? ______ Month _____Year

8a. Have you had wheezing or whistling in your chest

at any time in the last 12 months? 1. Yes ___ 0. No ___

IF YES:

8b. When did this wheezing or whistling start? ______ Month _____Year

8c. When you are away from this plant on days off

or on vacation, is this wheezing or whistling: 1.___ Same

2.___ Worse

3.___ Better

8d. Apart from when you have a cold, does
your chest ever sound wheezy or whistling? 1. Yes ___ 0. No ___

9a. Have you had a feeling of tightness in your chest

at any time in the last 12 months? 1. Yes ___ 0. No ___

IF YES:

9b. Have you woken up with a feeling of tightness in your chest

at any time in the last 12 months? 1. Yes ___ 0. No ___

IF YES:

9c. When did this awakening with a feeling of tightness in your chest start?

____ Month _____Year

9d. When you are away from this plant on days off

or on vacation, is this awakening with a feeling of tightness in your chest: 1.___ Same

2.___ Worse

3.___ Better

10a. Have you had an attack of asthma in the last 12 months? 1. Yes ___ 0. No ___

IF YES:

10b. When did these attacks of asthma start? _______ Month _____Year

10c. When you are away from this plant on days off

or on vacation, are your attacks of asthma: 1.___ Same

2.___ Worse

3.___ Better

11a. Are you currently taking any medicine (including inhalers,

aerosols, or tablets) for asthma? 1. Yes ___ 0. No ___

IF YES:

11b. When did you start using medicine for asthma? ______ Month _____Year

11c.When you are away from this plant on days off 1.___ Same

or on vacation, are your attacks of asthma: 2.___ Worse

3.___ Better

12a. Have you had any unusual tiredness or fatigue
during the last 12 months? 1. Yes ___ 0. No ___

IF YES:

12b. When did this tiredness or fatigue start? ______ Month _____Year

13a. Has a doctor ever told you that you had asthma? 1. Yes ___ 0. No ___

IF YES:

13b. When were you first told you had asthma? ______ Month _____Year

13c. Do you still have asthma? 1. Yes ___ 0. No ___

13d. If you no longer have asthma, how old were you
when your asthma stopped? ______ Age stopped

14a. Has a doctor ever told you that you had chronic bronchitis? 1. Yes ___ 0. No ___

IF YES:

14b.When were you first told you had chronic bronchitis? ______ Month _____Year

14c. Do you still have chronic bronchitis? 1. Yes ___ 0. No ___

15a. Has a doctor ever told you that you had emphysema? 1. Yes ___ 0. No ___

IF YES:

15b. When were you first told you had emphysema? ______ Month _____Year

16a. Has a doctor ever told you that you had COPD? 1. Yes ___ 0. No ___

IF YES:

16b. When were you first told you had COPD? ______ Month _____Year

17a. Has a doctor ever told you that you had

lung scarring or fibrosis? 1. Yes ___ 0. No ___

IF YES:

17b. When were you first told you had lung scarring or fibrosis? ______ Month _____Year

Section III. Work Information

Next, we are going to ask about your work history.

18. Please list all of the jobs you performed while at the facility on Sims Avenue or at the previous location on Harris Avenue. We want you to include any work you may have done at either of these locations prior to Umicore’s ownership in 2002 and any work as a temporary or contract employee. We will start with your first job and continue through to your most recent job.

Job Number	Department	Job Title	Start Date (mm/yyyy)	End Date (mm/yyyy)	Type of employee (Contract/Temporary/Umicore)	Major Work Area	Machines or tools used	Tasks performed	Materials or products handled
1
2
3
4
5
6

For each job listed, ask:

18a. What other departments or work areas did you work in during this time period?

____________________________________________________________________________

For current job, ask:

18b. Do you wear a respirator in this job? 1. Yes ___ 0. No ___

IF YES:

18c. How often did you wear the respirator:

1. Less than daily

2. Daily, less than 2 hours per day

3. Daily, 2 to 4 hours per day

4. Daily, over 4 hours per day

18d. For what tasks do you wear the respirator?

18e. Do you use different respirators for different tasks? 1. Yes ___ 0. No ___

18f. What type of respirator do you use most often?

1. Dust mask

2. Disposable N95

3. 1/2 face respirator

4. Full face respirator

5. PAPR

For questions 18g-18p, please respond for the respirator that you use most often:

18g. When you first got your respirator, were you fit tested? 1. Yes ___ 0. No ___

18h. When you use your respirator, do you do anything to check whether it fits properly? 1. Yes ___ 0. No ___

IF YES:

18i. Describe what you do to check whether your respirator fits properly: __________________________________________________________________

18j. Were you ever trained on the proper usage of the respirator? 1. Yes ___ 0. No ___

18k. Are respirator cartridges provided? 1. Yes ___ 0. No ___

18l. How often do you replace the respirator cartridges?

_____________________________________________________________________

18m. Do you clean your respirator? 1. Yes ___ 0. No ___

IF YES:

18n. How do you clean your respirator? (Interviewer, do not prompt by providing the options, but code responses to one or more of the following:)

1. water alone

2. soap and water

3. alcohol wipes

4. other:______________________

18o. How often do you clean your respirator?

__________________________________________________________________

18p. Where do you store your respirator?

_____________________________________________________________________

18p. Do you do anything else to maintain your respirator?

_____________________________________________________________________

Section IV. Tobacco Use Information

I’m now going to ask you a few questions about tobacco use.

19a. Have you ever smoked cigarettes? 1. ___ Yes 0. ___ No

(NO if less than 20 packs of cigarettes in a

lifetime or less than 1 cigarette a day for 1 year.)

IF YES:

19b. How old were you when you first started

smoking regularly? ______ Years old

19c. Over the entire time that you have smoked,

what is the average number of cigarettes

you smoked per day? ______ Cigarettes/day

19d. Do you still smoke cigarettes? 1. ___ Yes 0. ___ No

IF NO:

19e. How old were you when you stopped

smoking cigarettes regularly? ______ Years old

Thank you for participating in this survey!

PREGNANCY SCREENING QUESTIONS

Low-dose HRCT will not be offered to pregnant women, due to the potential risks of radiation to the fetus. To assess pregnancy status, all female participants of menstrual age (through age 50 years) will be asked privately about pregnancy status by the study’s medical officer using the following questions:

1. What was the first day of your last complete menstrual period?

Month _____ Day_____ Year_______

2. To the best of your knowledge, are you pregnant (or do you think you could be)?

Yes ____ No ____ Possibly/Not sure ____

3. If “No” to question 2, explain. ________________________________________________

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-xxxx).