monthly questionnaire

Attachment J-1

Monthly Questionnaire

Form Approved

OMB No. 0920-0260

Expires xx/xx/20xx

Study Title:

Evaluating Interventions for Airplane Cargo Baggage Handling

Public reporting burden of this collection of information is estimated to average 10 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN.: PRA (0920-xxxx). Do not send the completed form to this address.

Today's Date:__ __ / __ __ / __ __ __ __ Work site (3 letter airport code): ________

month day year

1. Last Name: __________________________________________________________

2. First Name: __________________________________________________________

3. Middle Initial: _____

4. Your Employee Number (or Clock Number): __________________

5. Did you change your job in the past month?  No  Yes

6. In the past month, how much time did you spend in cargo compartments loading/unloading baggage during your typical workday?

 More than 6 hours

 Greater than 4 to equal or less than 6 hours

 Greater than 2 to equal or less than 4 hours

 Equal or less than 2 hours

 I do not work in this position

7. In the past month, how much time did you spend in cargo compartments loading/unloading baggage using the Power Stow^® during your typical workday?

 More than 6 hours

 Greater than 4 to equal or less than 6 hours

 Greater than 2 to equal or less than 4 hours

 Equal or less than 2 hours

 I do not use the Power Stow

8. In the past month, how much time did you spend lifting bags to/from baggage carts during your typical workday?

 More than 6 hours

 Greater than 4 to equal or less than 6 hours

 Greater than 2 to equal or less than 4 hours

 Equal or less than 2 hours

 I do not work in this position

9. In the past month, how much time did you spend on using the vacuum lift during your typical day?

 More than 6 hours

 Greater than 4 to equal or less than 6 hours

 Greater than 2 to equal or less than 4 hours

 Equal or less than 2 hours

 I do not use the vacuum lift

10. In the past month, have you had any symptoms (ache, pain, stiffness, burning, numbness, tingling) in:	To be answered only by those who have had symptoms
	Did you see a doctor for the symptoms?	Did you take sick leave for the symptoms?
Neck  No (Skip to shoulders)  Yes	 No  Yes	 No  Yes
Shoulders  No (Skip to low back)  Yes	 No  Yes	 No  Yes
Low back  No (Skip to knees)  Yes	 No  Yes	 No  Yes
Knees  No  Yes	 No  Yes	 No  Yes

11. Are you pregnant?  No  Yes  Not applicable

(The reason for asking the above question is to assure that the reported symptoms are work-related)