Att K_Screening

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Oil and Gas Workers Safety and Health Survey

Opening Script and Screening Form

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Hello, my name is _______________. On behalf of the National Institute for Occupational Safety and Health (NIOSH), I appreciate the opportunity to talk to you about an important safety and health survey we are conducting with workers in the oil and gas extraction industry. This survey consists of four parts: the first part asks several basic questions about you like your age and other demographics. The second part asks questions about injuries, hazards, general safety and your use of personal protective equipment. The third part asks about your driving behaviors, if you drive a vehicle as part of your job duties. The fourth part asks about your safety and health concerns at work and will be asked by an interviewer.

Participation is strictly voluntary, all information collected will be confidential, and your name will not be recorded at any time. You can stop at any time and only answer questions that you want to. Also, you will receive a $30 gift card as a token of our appreciation.

Overall, the survey should take about 30 minutes to complete.

Would you like to be screened to see if you qualify to participate?

1. Have you worked in the oil and gas extraction industry for at least 1 month during the past year?

• YES

• NO

2. Do your work duties take you onto a well-site at least 2 days per week or more?

• YES

• NO

If the answer is yes for both questions, worker is eligible. Provide worker with consent form to review.

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 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).