Form 0920-15XT Att C Demographic Questionaire

Attachment C

Demographic Questionnaire

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Demographic Questionnaire Participant # _______

Gender: Male _____ Female _____ Date of Birth: __________________

Work Experience:

Number of Years Working in Mining: ___________________

Current Job Title: ____________________________________

Number of Years in Current Job Title: ________________________________

Typical Tasks Performed during Current Work Day:_________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Other Job Titles Held: _________________________________________________________________

Training:

Training and Certification (examples: New Miner, CPR, etc.):

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Have you received training on how to perform a risk assessment? Yes No

Have you received any hazard specific training? Yes No

If yes, what type of training did you receive?

Public reporting burden of this collection of information is estimated to average 6 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)