Demographic Questionnaire

Appendix S: Demographic Questionnaire

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/20xx

Subject ID

Testing Date

/

/

Month Day Year

Gender

Male

Female

Anthropometry

Height

cm

Weight

.

kg

Current Job Title

Current Job Title:

Years in Current Job Title:

.

Years

Shift Length:

.

Hours

Shifts per Week:

.

Shift

Today’s Shift:
	1st (Daylight)
	2nd (Afternoon)
	3rd (Cat-eye)
	Other:__________

Shift Rotation:
	None
	1st & 2nd
	1st, 2nd, & 3rd
	Other:____________

Shift Rotation Schedule:
	None
	Every Week
	Every Two Weeks
	Other:____________

Mining Experience

Other Positions Worked:

Total Mining Experience:

.

Years

Number of Mines Worked:

Mines

Public reporting burden of this collection of information is estimated to average 2 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-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).