Attachment C
Form Approved
OMB No. 0920-1154
Exp. Date 1/31/2020
Attachment C
Miner Demographic Questionnaire
What is your age? years old
Have you ever participated in a voluntary black lung screening? (select one)
☐ Yes
☐ No
☐ I don’t remember
How many times have you participated in a voluntary black lung screening? (select one)
☐ Never/0 times
☐ 1-3 times
☐ 4-6 times
☐ 7-8 times
☐ 9-10 times
☐ More than 10 times
☐ I don’t remember
What is your employment status? (select one)
☐ I work for a mine
☐ I work as a contractor for a mine
☐ I am a retired miner
☐ I am a former miner, but I am not retired
Public reporting burden of this collection of information is estimated to average 5 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).
What positions have you worked in as a miner?
Total number of years in mining?
In which type(s) of mines have you worked? (select all that apply)
☐ Metal |
☐ Underground |
☐ Nonmetal |
☐ Surface |
☐ Stone |
☐ Mills and prep plants |
☐ Sand and Gravel |
☐ Other: |
In which states have you worked as a coal miner? (select all that apply)
Appalachian Coal Region* |
Interior Coal Region* |
Western Coal Region* |
☐ Alabama |
☐ Arkansas |
☐ Alaska |
☐ Eastern Kentucky |
☐ Illinois |
☐ Arizona |
☐ Maryland |
☐ Indiana |
☐ Colorado |
☐ Ohio |
☐ Kansas |
☐ Montana |
☐ Pennsylvania |
☐ Louisiana |
☐ New Mexico |
☐ Tennessee |
☐ Mississippi |
☐ North Dakota |
☐ Virginia |
☐ Missouri |
☐ Utah |
☐ West Virginia |
☐ Oklahoma |
☐ Washington |
☐ Texas |
☐ Wyoming |
|
☐ Western Kentucky |
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*Source: U.S. Energy Information Administration
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Swanson, LaTasha (CDC/NIOSH/PMRD/HFB) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |