App G_Preliminary Survey for Boot Wear Evaluation

Appendix G

Preliminary Survey for Boot Wear Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Assigned participant ID: __________ Date: ____ / _____ / 20 _____

Photo of boots: Yes / No Scan of boots: Yes / No Harris mat: Yes / No

Hardness measure: ¬¬¬¬¬¬_________

Recorded by: MFN / PD / WP / JP / AM / JM

Demographics:

1. Age: __________ years

2. Gender: Male / Female

3. Height: __________ ft __________ in

4. Weight: ___________ lbs

Work History

1. Current job title: ______________________________

2. What shifts do you most commonly work? (mark one or more that apply)

 Day

 Evening

 Night

3. On average number of hours worked per week: __________ hours

4. Number of years in current job title: __________ years

5. Number of years at current mine: __________ years

6. Number of years of total mining experience: __________ years

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Work boots

1. Make of boots you are currently wearing: ____________________

2. Model of boots you are currently wearing: ____________________

(If you cannot identify or do not know the make and model of your boots, please show the boots to the researcher so they can help you)

3. Please select the safety features of your current boots

 composite toe

 steel toe

 metatarsal guard

 other (please specify) ___________________________________________________________

4. Do you wear your work boots outside of work? Yes / No

5. How long have you been wearing these boots? ____________________________________

6. Using the scale below, please rate your current level of comfort while wearing your work boots:

No discomfort 0 1 2 3 4 5 Intolerable Discomfort

7. If you had a choice of wearing your current boots again, would you?

 Yes, I hope to get these boots again.

 Yes, I would wear them again.

 No, I prefer: Please provide make and model -____________________________________________

 No, I would not wear them again.

 Please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Recent Slip, trip, and fall history

1. Have you had a slip within the past 3 months: Yes / No

(A slip is defined as simply a loss of traction of the foot; you can slip without falling. In general, if your foot slides, you have slipped. You might not have fallen even though you slipped.)

If Yes, please specify when the event occurred and describe the sequence of events leading up to the slip.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Have you tripped within the past 3 months: Yes / No

(A trip is defined as something that prevents the foot from coming fully through its normal swing phase of the walking motion; you can trip without falling. In general, if the foot stops before making heel contact, you have tripped. You might not have fallen even though you tripped.)

If Yes, please specify when the event occurred and describe the sequence of events leading up to the trip.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Have you fallen within the past 3 months: Yes / No

If Yes, please specify when the event occurred and describe the sequence of events leading up to the fall.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________