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Attachment
C
Pre/Post
Mine Worker Survey
Form
Approved
OMB No. 0920-xxxx Exp.Date xx/xx/20xx
Pre/Post
Mine Worker Survey - The
purpose of these questions is to try to understand
what you
think has the biggest impact on health and safety at this operation.
Please
think about a typical work week when responding.
To
protect your identity:
Your
supervisors will not see your individual responses.
These
forms will not be made available to any
management personnel.
We
will combine the data from everyone into larger groups to describe
the results.
Strongly
Disagree
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Disagree
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Somewhat
Disagree
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Somewhat
Agree
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Agree
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Strongly
Agree
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Please mark the
number below each statement or question that best describes your
opinion using the following scale.
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When I’m at work I…
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Strongly
Strongly
Disagree
Agree
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When doing my job...
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Agree
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Public
reporting burden of this collection of information is estimated
to average 15 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).
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As far as day to day work…
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Strongly
Strongly
Disagree
Agree
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2
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3
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5
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6
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My supervisor…
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Strongly
Strongly
Disagree
Agree
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Everyone in my work crew…
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Strongly
Strongly
Disagree
Agree
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When it comes to the health and
safety rules and procedures in place at this operation…
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Strongly
Strongly
Disagree
Agree
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I know how to…
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Strongly
Strongly
Disagree
Agree
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It is important to…
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Strongly
Strongly
Disagree
Agree
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When
it comes to health and safety training…
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Strongly
Strongly
Disagree
Agree
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6
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In
general I think that…
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Strongly
Strongly
Disagree
Agree
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2
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3
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5
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6
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Over
the last 6 months on your job how often were you…
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Never
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Once
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Two
times
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Three
times
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Four
times
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+
Five times
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2
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Demographic
Items (circle or check item)
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18-24
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25–34
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35–44
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45–54
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55–64
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65–74
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75
+
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Male
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Female
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Hourly
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Salary
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0–3
mths
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3–6
mths
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6–12
mths
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1-5
yrs
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5
+ yrs
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0–3
mths
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3–6
mths
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6–12
mths
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1-5
yrs
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5
+ yrs
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0–3
mths
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3–6
mths
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6–12
mths
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1-5
yrs
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5
+ yrs
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Production
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Maintenance
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Safety
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Engineering
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Other
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6
am – 9:59 am
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10
am – 1:59 am
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2pm
– 5:59 am
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6
pm-9:59pm
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10
pm – 1:59 am
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2
am- 5:59 am
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Start
at the same time every day
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Rotate
between different starting times
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First
generation miner
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Multi-generation
miner
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Less
than high school
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High
school
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Associate
Degree/
Trade certificate
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Bachelor’s
degree
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Master’s
degree
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Married/Domestic
partnership
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Divorced
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Widowed
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Separated
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Single,
never been married
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Yes
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No
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Less
than 5 years old
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5
through 12 years old
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13
through 17 years old
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18
or older
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Extremely
tired
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Tired
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Somewhat
tired
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Somewhat
awake
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Wake
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Wide
awake
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The
following questions concern your Continuous Personal Dust Monitor
(CPDM). There are several reasons why you may or may not want to
utilize your CPDM to manage your respirable dust exposure. Different
people have different reasons for participating in health-related
behaviors, and we want to know how true each of these reasons is for
you. There are three groups of items. The items pertain to the
sentence that begins each group. Please
indicate how true each reason is for you using the following scale:
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Not true at all
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2
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3
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4
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5
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6
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Very true
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I
will participate actively in utilizing my CPDM to lower my
exposure to respirable dust because…
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Not
true
Very
at all
true
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3
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4
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6
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I am likely to follow my
supervisor’s/organization’s suggestions for
utilizing my CPDM because…
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Not
true
Very
at all
true
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I will continue to use my CPDM
because…
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Not
true
Very
at all
true
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Thank
you for your participation in this survey.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Emily Haas |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |