Application of a Web-Based Health Survey Tool in Schools

Appendix E. Non-respondent Survey Questionnaire

Form Approved

OMB No. 0920-XXXX

Expires XX/XX/XXXX

ID

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

School Questionnaire

The National Institute for Occupational Safety and Health (NIOSH) recently conducted an on-line health questionnaire of employees in your school district. We are asking a random sample of people who did not participate in this questionnaire to answer a short health questionnaire. This should only take a few minutes to complete. All responses are considered confidential in accordance with the Privacy Act of 1974 (Public Law 93-579). Please return the completed questionnaire in the enclosed postage-paid envelope. Thank you for your consideration in taking part in this survey.

“BY COMPLETING THIS QUESTIONNAIRE, YOU INDICATE YOUR CONSENT TO PARTICIPATE IN THIS STUDY.”

Reasons for Non-Response

1. We are trying to better understand why people decide to participate or not participate in health surveys. Can you please tell us the main reason why you declined to complete your health survey? (select the option that most applies)

_____Not interested in topic

_____Survey is too long and/or too busy to complete

_____Don’t like sharing information on topic

_____Dislike or choose not to participate in surveys

_____Distrust how information will be used

_____Would like to be compensated for time

_____Does not support government research

_____Concerned about confidentiality/privacy

_____Other (Please specify______________________________________)

Respiratory Symptoms

2. In the past 12 months have you had….

Symptom	Yes	No
A. Wheezing or whistling in your chest?
B. Chest tightness?
C. Attacks of shortness of breath?
D. Attacks of cough?
E. Awakened by an attack of breathing difficulty?

If YES to any of 2A, B, C, D, or E:

2.1 When you were away from school on weekends, days off, or vacations, are the

symptoms: ___Same ___Worse ___Better

Asthma

3. Has a physician ever told you that you have asthma? Yes_____ No_____

IF YES:

3A. Date of asthma diagnosis: __ __ / __ __ __ __

(Mo.) (Year)

Demographics

4. Year of Birth: __ __ __ __

5. Gender: ____ Male

____ Female

6. Ethnicity (Please choose one):

____ Hispanic or Latino

____ Not Hispanic or Latino

7. Race (Please choose all that apply):

____ American Indian or Alaska Native

____ Asian

____ Black or African American

____ Native Hawaiian or Other Pacific Islander

____ White

Job Information

8. Please indicate your current job title:

_____Teacher

_____Teacher’s Aide/Assistant

_____School Administration

_____Office Staff

_____School Engineer

_____Maintenance

_____Custodian/Janitorial/Cleaning

_____Medical Staff

_____Library Staff

_____Counselor

_____Security

_____Cafeteria/Kitchen Worker

_____Other (specify_____________)

Smoking History

9 Have you ever smoked cigarettes regularly? ___Yes ___No

(Please mark “No” if you have smoked less than 100 cigarettes in your lifetime.)

IF YES:

9.1 Do you still smoke cigarettes? ___Yes ___No

THANK YOU FOR YOUR TIME!

Public reporting burden of this collection of information is estimated to average 5 minutes 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).