Appendix D: School Health Questionnaire
Form Approved
OMB No. 0920-XXXX
Expires
Dear School District Employee,
The National Institute for Occupational Safety and Health (NIOSH) would like to thank you for participating in this health questionnaire survey. The purpose of this survey is to collect data that may be useful for studying the association between health symptoms and damp conditions in 50 selected elementary schools.
The questionnaire should take a maximum of 20 minutes to complete, and you can stop at any point if necessary. Completed sections would be saved until you were able to return and complete the questionnaire.
CONSENT:
Your participation is voluntary. You may choose to be in the study or not. You can choose to answer any or all of the questions. You may drop out any time, for any reason, without consequences to you. NIOSH is authorized to collect your personal information and will protect it to the extent allowed by law. There are conditions under the Privacy Act where your information may be released to collaborators or contractors, health departments or disease registries, to the Departments of Justice or Labor, or to Congressional offices. Any risks from completing this survey are minimal. The only risk we anticipate is the potential for loss of confidentiality. To minimize this risk all data is stored on a secure server at the Centers for Disease Control and Prevention, and only those authorized to work on this study will be able to see your results. For questions about your rights, your privacy, or harm to you, contact the Director of Human Research Protections, Mark Toraason at [email protected], or 513-533-8591. There are no direct benefits to you personally for participating in the study. However, what we learn may reduce health symptoms in school employees by providing proper approaches for responding to dampness in school buildings.
By completing the questionnaire, you give your consent to participate.
____________________________________________
Public reporting burden of this collection of information is estimated to average 20 minutes or less 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 NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
1. Date of Birth: __ __ / __ __ / __ __ __ __
Month Day Year
2. Gender: ____ Male
____ Female
3. Ethnicity (Please choose one):
____ Hispanic or Latino
____ Not Hispanic or Latino
4. Race (Please choose all that apply):
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Native Hawaiian or Other Pacific Islander
____ White
Employment History:
5. What is the date you first started work in this school system? __ __ /__ __ __ __
Mo Yr
6. Please indicate your current job title: _____Teacher
Grade taught (drop down)
_____Teacher’s Aide/Assistant
Grade taught (drop down)
_____School Administration
_____Office Staff
_____School Engineer
_____Maintenance _____Custodian/Janitorial/Cleaning _____Medical Staff
_____Library Staff
_____Counselor
_____Security
_____Cafeteria/Kitchen Worker
_____Other (specify_____________)
7. How many schools have you worked at in this school district in the past 12 months? _____
(Number generates loop number)
School Name (drop down)
Currently working at school? ___Yes ___No
Date started: __ __ /__ __ __ __
Mo Yr
Date ended: __ __ /__ __ __ __ or current
Mo Yr
Please list all rooms in this school in which you spend/spent four or more hours a week. For each room listed, please also indicate the total number of hours per week.
Room name/Room number |
Hours per Week |
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School Name (drop down)
Currently working at school? ___Yes ___No
Date started: __ __ /__ __ __ __
Mo Yr
Date ended: __ __ /__ __ __ __ or current
Mo Yr
Please list all rooms in this school in which you spend/spent four or more hours a week. For each room listed, please also indicate the total number of hours per week.
Rooms Spent Most Time in |
Hours per Week |
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School Name (drop down)
Currently working at school? ___Yes ___No
Date started: __ __ /__ __ __ __
Mo Yr
Date ended: __ __ /__ __ __ __ or current
Mo Yr
Please list all rooms in this school in which you spend/spent four or more hours a week. For each room listed, please also indicate the total number of hours per week.
Rooms Spent Most Time in |
Hours per Week |
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Health Symptoms
The following questions are about your health. If you don’t know whether to answer yes or no to a particular question, please answer no.
4.1 During the past 12 months have you had wheezing or whistling in your chest ___Yes ___No
at any time?
IF YES:
4.2 When you were away from school on weekends, days off, or vacations, is the wheezing or whistling:
___Same ___Worse ___Better
4.3 Have you had wheezing or whistling in your chest in the last 4 weeks? ___Yes ___No
IF YES:
4.3.1 Have you had wheezing or whistling in your chest one or more times per ___Yes ___No
week in the last 4 weeks?
5.1 During the past 12 months have you had chest tightness? ___Yes ___No
IF YES:
5.2 When you were away from school on weekends, days off, or vacations, is the chest tightness:
___Same ___Worse ___Better
5.3 Have you had chest tightness in the last 4 weeks? ___Yes ___No
IF YES:
5.3.1 Have you had chest tightness one or more times per week in the last ___Yes ___No
4 weeks?
6.1 During the past 12 months have you had attacks of shortness of breath? ___Yes ___No
IF YES:
6.2 When you were away from school on weekends, days off, or vacations, are the attacks of shortness of breath: ___Same ___Worse ___Better
6.3 Have you had attacks of shortness of breath in the last 4 weeks? ___Yes ___No
IF YES:
6.3.1 Have you had attacks of shortness of breath one or more times per week ___Yes ___No
in the last 4 weeks?
7.1 During the past 12 months have you had attacks of cough? ___Yes ___No
IF YES:
7.2 When you were away from school on weekends, days off, or vacations, are the attacks of cough:
___Same ___Worse ___Better
7.3 Have you had attacks of cough in the last 4 weeks? ___Yes ___No
IF YES:
7.3.1 Have you had attacks of cough one or more times per week in the last ___Yes ___No
4 weeks?
8.1 During the past 12 months have you been awakened by an attack of breathing ___Yes ___No
difficulty?
IF YES:
8.2 When you were away from school on weekends, days off, or vacations, is the awakening by attacks of
breathing difficulty: ___Same ___Worse ___Better
8.3 Have you been awakened by an attack of breathing difficulty in the last ___Yes ___No
4 weeks?
IF YES:
8.3.1 Have you been awakened by an attack of breathing difficulty one or more ___Yes ___No
times per week in the last 4 weeks?
9.1 During the past 12 months, have you had shortness of breath walking with ___Yes ___No people of your own age on level ground?
IF YES:
9.2 When you were away from school on weekends, days off, or vacations, is this shortness of breath: ___Same ___Worse ___Better
9.3 Have you had shortness of breath walking with people of your own age on ___Yes ___No
level ground in the past 4 weeks?
IF YES:
9.3.1 Have you had shortness of breath walking with people of your own ___Yes ___No
age on level ground one or more times per week in the past 4 weeks?
10.1 During the past 12 months have you had any episodes of stuffy, itchy ___Yes ___No
or runny nose?
IF YES:
10.2 When you were away from school on weekends, days off, or vacations, is the stuffy, itchy or runny nose: ___Same ___Worse ___Better
10.3 Have you had a stuffy, itchy or runny nose in the last 4 weeks? ___Yes ___No
IF YES:
10.3.1 Have you had a stuffy, itchy or runny nose one or more times ___Yes ___No
per week in the last 4 weeks?
11.1 During the past 12 months have you had sinusitis or sinus problems? ___Yes ___No
IF YES:
11.2 When you were away from school on weekends, days off, or vacations, are the sinusitis or sinus problems: ___Same ___Worse ___Better
11.3 Have you had sinusitis or sinus problems in the last 4 weeks? ___Yes ___No
IF YES:
11.3.1 Have you had sinusitis or sinus problems one or more times per ___Yes ___No
week in the last 4 weeks?
12.1 During the past 12 months have you had a sore or dry throat? ___Yes ___No
IF YES:
12.2 When you are away from school on weekends, days off, or vacations, is the sore or dry throat:
___Same ___Worse ___Better
12.3 Have you had a sore or dry throat in the last 4 weeks? ___Yes ___No
IF YES:
12.3.1 Have you had a sore or dry throat one or more times per week in ___Yes ___No
the last 4 weeks?
13.1 During the past 12 months have you had dry or itchy skin? ___Yes ___No
IF YES:
13.2 When you were away from school on weekends, days off, or vacations, is the dry or itchy skin:
___Same ___Worse ___Better
13.3 Have you had dry or itchy skin in the last 4 weeks? ___Yes ___No
IF YES:
13.3.1 Have you had dry or itchy skin one or more times per week ___Yes ___No
in the last 4 weeks?
14.1 During the past 12 months have you had any episodes of watery, itchy eyes? ___Yes ___No
IF YES:
14.2 When you are away from school on weekends, days off, or vacations, are the watery or itchy eyes: ___Same ___Worse ___Better
14.3 Have you had watery or itchy eyes in the last 4 weeks? ___Yes ___No
IF YES:
14.3.1 Have you had watery or itchy eyes one or more times per week ___Yes ___No
in the last 4 weeks?
15.1 During the past 12 months have you had episodes of fever and chills? ___Yes ___No
IF YES:
15.2 When you were away from school on weekends, days off, or vacations, are these episodes of fever and chills ___Same ___Worse ___Better
15.3 Have you had episodes of fever and chills in the last 4 weeks? ___Yes ___No
last 4 weeks?
IF YES:
15.3.1 Have you had episodes of fever and chills one or more times ___Yes ___No
per week in the last 4 weeks?
16.1 During the past 12 months have you had episodes of flu-like achiness ___Yes ___No
or achy joints?
IF YES:
16.2 When you were away from school on weekends, days off, or vacations, is the
flu-like achiness or achy joints: ___Same ___Worse ___Better
16.3 Have you had episodes of flu-like achiness or achy joints in the ___Yes ___No
last 4 weeks?
IF YES:
16.3.1 Have you had episodes of flu-like achiness or achy joints ___Yes ___No
one or more times per week in the last 4 weeks?
17.1 During the past 12 months have you had unusual tiredness or fatigue? ___Yes ___No
IF YES:
17.2 When you were away from school on weekends, days off, or vacations, is the unusual tiredness
or fatigue: ___Same ___Worse ___Better
17.3 Have you had unusual tiredness or fatigue in the last 4 weeks? ___Yes ___No
IF YES:
17.3.1 Have you had unusual tiredness or fatigue one or more times ___Yes ___No
per week in the last 4 weeks?
18.1 During the past 12 months have you had difficulty remembering things? ___Yes ___No
IF YES:
18.2 When you were away from school on weekends, days off, or vacations, is the difficulty
remembering things: ___Same ___Worse ___Better
18.3 Have you had
difficulty remembering things in the last 4 weeks?
___Yes ___No
IF YES:
18.3.1 Have you had difficulty remembering things one or more times ___Yes ___No
per week in the last 4 weeks?
19.1 During the past 12 months have you had difficulty concentrating? ___Yes ___No
IF YES:
19.2 When you were away from school on weekends, days off, or vacations, is the difficulty concentrating: ___Same ___Worse ___Better
19.3 Have you had difficulty concentrating in the last 4 weeks? ___Yes ___No
IF YES:
19.3.1 Have you had difficulty concentrating one or more times per ___Yes ___No
week in the last 4 weeks?
20.1 During the past 12 months have you had confusion or disorientation? ___Yes ___No IF YES:
20.2 When you were away from school on weekends, days off, or vacations, is the confusion or disorientation: ___Same ___Worse ___Better
20.3 Have you had confusion or disorientation in the last 4 weeks? ___Yes ___No
IF YES:
20.3.1 Have you had confusion or disorientation one or more times per ___Yes ___No
week in the last 4 weeks?
21.1 During the past 12 months have you had dizziness or lightheadedness? ___Yes ___No
IF YES:
21.2 When you were away from school on weekends, days off, or vacations, is the dizziness or lightheadedness: ___Same ___Worse ___Better
21.3 Have you had dizziness or lightheadedness in the last 4 weeks? ___Yes ___No
IF YES:
21.3.1 Have you had dizziness or lightheadedness one or more times ___Yes ___No
per week in the last 4 weeks?
22.1 During the past 12 months have you had headaches? ___Yes ___No
IF YES:
22.2 When you were away from school on weekends, days off, or vacations,
are the headaches: ___Same ___Worse ___Better
22.3 Have you had headaches in the last 4 weeks? ___Yes ___No
IF YES:
22.3.1 Have you had headaches one or more times per week in the last 4 weeks? ___Yes ___No
Infections
23.1 During the past 12 months have you had an influenza-like illness (an episode ___Yes ___No
of fever and cough that came on rapidly, lasted for one or more days, and may
have also included fatigue, muscle aches, or sore throat)?
IF YES:
23.2 Have you had an influenza-like illness in the last 4 weeks? ___Yes ___No
24.1 In the past 12 months have you had pneumonia? ___Yes ___No
IF YES:
24.2 Have you had pneumonia in the last 4 weeks? ___Yes ___No
25.1 In the past 12 months have you had acute bronchitis? ___Yes ___No
IF YES:
25.2 Have you had acute bronchitis in the last 4 weeks? ___Yes ___No
26.1 During the past 12 months have you had a sudden onset of nausea, vomiting, ___Yes ___No
or diarrhea for one or more days?
IF YES:
26.2 Have you had a sudden onset of nausea, vomiting, or diarrhea that lasted ___Yes ___No
for one or more days in the last 4 weeks?
27. During the past 12 months have you had an upper respiratory infection which has involved the…
CONDITION |
Yes |
No |
27.1 Nose? |
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27.2 Sinuses? |
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27.3 Throat? |
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27.4 Ears? |
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27.5 Common cold? |
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Medical Conditions
28.1 Has a doctor or other health professional ever told you that you ___Yes ___No
have asthma?
IF YES:
28.2 In what month and year were you first diagnosed with asthma? __ __ / __ __ __ __
Month Year
28.3 Do you still have asthma? ___Yes ___No
29.1 Has a doctor or other health professional ever told you that you ___Yes ___No
have hypersensitivity pneumonitis?
IF YES:
29.2 In what month and year were you first diagnosed with __ __ / __ __ __ __
hypersensitivity pneumonitis? Month Year
30.1 Has a doctor or other health professional ever told you that you ___Yes ___No
have sarcoidosis?
IF YES:
30.2 In what month and year were you first diagnosed with sarcoidosis? __ __ / __ __ __ __
Month Year
31. Has a doctor or other health professional ever told you that you have…
CONDITION |
Yes |
No |
31.1 Nasal or sinus allergies, including hay fever? |
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31.2 Eczema or any kind of skin allergy? |
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31.3 Allergies to animals? |
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31.4 Allergies to dust or dust mites? |
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31.5 Chronic bronchitis? |
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31.6 Emphysema? |
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31.7 Heart disease? |
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31.8 Chronic Obstructive Pulmonary Disease (COPD)? |
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32.1 Has a doctor or other health professional ever told you that you ___Yes ___No
have any other respiratory condition?
IF YES:
32.2 Name of respiratory condition: _______________________________________________________
32.3 In what month and year were you first diagnosed with this condition? __ __ / __ __ __ __
Month Year
32.4 Do you still have this condition? ___Yes ___No
Work Days Missed Due to Health Problems
33.1 In the past 12 months, how many days have you missed work _______ Days
because of respiratory health problems?
34.1 In the past 12 months, how many days have you missed work _______ Days
because of health problems other than respiratory?
35.1 During the past 12 months, have you observed water leakage or water ___Yes ___No
damage indoors on walls, floors, or ceiling in your house or apartment?
IF YES:
35.2 Have you observed water leakage or water damage indoors in the ___Yes ___No
last 4 weeks in your house or apartment?
36.1 During the past 12 months, have you observed visible mold growth (not ___Yes ___No
on food) indoors on walls, floors, or ceilings?
IF YES:
36.2 Have you observed visible mold growth indoors on walls, floors, ___Yes ___No
or ceilings in your house or apartment?
37.1 During the past 12 months, have you observed an odor of mold or ___Yes ___No
mildew (not from food) in your house or apartment?
IF YES:
37.2 Have you observed an odor of mold or mildew in the last 4 weeks in ___Yes ___No
your house or apartment?
Smoking History
38.1 Have you ever smoked cigarettes regularly? ___Yes ___No
(Please mark “No” if you have smoked less than 100 cigarettes in your lifetime.)
IF YES:
38.2 Do you still smoke cigarettes? ___Yes ___No
General Comments
39.1 Do you have any other additional comments or concerns? ___Yes ___No
IF YES:
39.2 Please describe:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Thank you for your time in completing this survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Brian Tift |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |