Focus group demographic survey

Attachment E

Form Approved

OMB No. 0920-1154

Exp. Date 1/31/2020

Attachment E

Stakeholder Demographic Questionnaire

1. What is your age? years old

2. Have you ever participated in a voluntary black lung screening? (select one)

☐ Yes

☐ No

☐ I don’t remember

3. 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

4. Have you ever worked as a miner? (select one)

☐ Yes, I work for a mine

☐ Yes, I work as a contractor for a mine

☐ Yes, I am a retired miner

☐ Yes, I am a former miner, but I am not retired

☐ No

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).

5. If you have worked as a miner. 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:
☐ N/A

6. 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

*Source: U.S. Energy Information Administration

7. Total number of years working in the mining sector (all positions)?

8. For which type of organization do you currently work? (select one)

☐ Mining company	☐ Vendor/Supplier
☐ Regulatory/enforcement agency	☐ Original Technology Manufacturer (OTM)
☐ Law Firm	☐ Original Equipment Manufacturer (OEM)
☐ Consulting	☐ Mining Association
☐ Training Provider	☐ Healthcare Provider
☐ Insurance Company	☐ Research/Academic
☐ Other: