Att C_Oil and Gas Workers Safety and Health Survey-Module 2,3,5 (WEB)

Attachment C

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Oil and Gas Workers Safety and Health Survey

1. (M1)- General

Demographic Characteristics

1. How old are you? Age

Age:____

2. What is your gender? gender

• Male 1

• Female 2

1. Do you consider yourself to be Hispanic or Latino? Hispanic

• Yes 1

• No 2

• Don’t know 99

4. What race or races do you consider yourself to be?

Please select the ones which best describe you. Race

• White White

• Black or African American Black

• American Indian or Alaska Native AIAN

• Native Hawaiian or Pacific Islander Hawaiian

• Asian Asian

5. What is the highest level of education you have completed? education

• 8^th grade or less 1

• 9^th-12^th grade (no diploma) 2

• GED or equivalent 3

• High school graduate (diploma) 4

• Some college (no degree) 5

• Associate degree 6

• Bachelor’s degree or higher 8

• Don’t know 99

6. What state do you currently work in?

State: ____________________ workState

7. What state do you consider your home?

State: ___________________ homeState

Worker Information, Schedule, Commuting

8. How long have you worked in the land-based oil and gas extraction industry?

Years: ____________________ oilfieldYears

Months:____________________ oilfieldMonths

9. What is your occupation or job title?

Occupation/Job Title: ________________________________________ occupation

10. Which of these reflect your day to day work schedule? schedule

• Day shift (around 7am-7pm) 1

• Evening/night shift (around 7pm-7am) 2

• Rotating shift (days and nights) 3

• Normal business hours (around 8a-5p) 4

• Other 97 (please specify): __________________________scheduleO

11. What is your current rotation? that is, how many days on, days off?

___________ Days On ____________ Days off

12. How many hours do you typically work in a day including overtime?

Hours: _________ workHrs

13. How many days per month do you typically work?

Days: _________ workMonth

14. On days when you are working, where do you go in your off time to eat, sleep and rest? rotation

• Home 1  Go to 2.16

• Man-camp 2

• Hotel 3

• Other 97 (please specify): ____________________ rotationO

15. When you started your last rotation, how long did it take to get from home to the place you work?

Hours: _________ remoteCommute

16. On average, how much time do you spend traveling to and from your work site each day when you are on-duty?

Pilot test and focus group question

Hours: ____________________ wrkCommuteHrs

Minutes:____________________ wrkCommuteMin

Company Information

17. What type of company do you work for? typeComp

• Drilling contractor 1

• Well servicing company 2

• Operator 3

• Other 97 (please specify): __________________________typeCompO

• Don’t know 99

1. About how many employees does your company have? numEmp

• Less than 10 1

• 10-19 2

• 20-99 3

• 100 or more 4

• Don’t know 99

Health and Personal Habits

19. Have you ever been told by a doctor or other health professional that you had...

    Angina or coronary heart disease angina	Yes 1	No 2	Don’t know 99
    Heart attack heartAttack	Yes 1	No 2	Don’t know 99
    Stroke stroke	Yes 1	No 2	Don’t know 99
    High blood pressure or hypertension hypertension	Yes 1	No 2	Don’t know 99
    High cholesterol cholesterol	Yes 1	No 2	Don’t know 99
    Diabetes diabetes	Yes 1	No 2	Don’t know 99
    Lung Disease (including obstructive lung disease or chronic lower respiratory disease) lungDisease	Yes 1	No 2	Don’t know 99
    Chronic bronchitis chronBron	Yes 1	No 2	Don’t know 99
    Emphysema emphysema	Yes 1	No 2	Don’t know 99
    Silicosis silicosis	Yes 1	No 2	Don’t know 99
    Pneumothorax pneumothorax	Yes 1	No 2	Don’t know 99

20. Have you ever been told by a doctor or other health professional that you had cancer? cancerDx

• Yes1

• No2  Go to 2.22.

21. What kind of cancer was it and how old were you when you were diagnosed?

Please check and specify age diagnosed for all that apply.

Yes (1), No (2)

• Bladder bladderDx Age diagnosed:_________ bladderAge

• Blood bloodDx Age diagnosed:_________ bloodAge

• Bone boneDx Age diagnosed:_________ boneAge

• Brain brainDx Age diagnosed:_________ brainAge

• Breast breastDx Age diagnosed:_________ breastAge

• Cervical cervicalDx Age diagnosed:_________ cervicalAge

• Colon colonDx Age diagnosed:_________ colonAge

• Esophageal esophagealDx Age diagnosed:_________ esophagealAge

• Gallbladder gallbladderDx Age diagnosed:_________gallbladderAge

• Renal (kidney) renalDx Age diagnosed:_________ renalAge

• Larynx( windpipe) larynxDx Age diagnosed:_________ larynxAge

• Leukemia leukDx Age diagnosed:_________ leukAge

• Liver liverDx Age diagnosed:_________ liverAge

• Lung lungDx Age diagnosed:_________ lungAge

• Lymphoma lymphomaDx Age diagnosed:_________ lymphomaAge

• Melanoma melanDx Age diagnosed:_________ melanDxAge

• Mouth, tongue, or lip mouthDx Age diagnosed:_________ mouthAge

• Ovarian ovarianDx Age diagnosed:_________ ovarianAge

• Pancreatic pancreaticDx Age diagnosed:_________ pancreaticAge

• Prostate prostateDx Age diagnosed:_________ prostateAge

• Rectal rectalDx Age diagnosed:_________ rectalAge

• Skin (non-melanoma) skinNonMelDx Age diagnosed:_________ skinNonMelAge

• Skin (not sure what kind) skinODx Age diagnosed:_________ skinOAge

• Soft tissue (muscle or fat) softTissDx Age diagnosed:_________ softTissAge

• Stomach stomachDx Age diagnosed:_________ stomachAge

• Testicular testicularDx Age diagnosed:_________ testicularAge

• Pharynx (throat) pharynxDx Age diagnosed:_________ pharynxAge

• Thyroid thyroidDx Age diagnosed:_________ thyroidAge

• Uterine (Endometrial) endometrialDx Age diagnosed:_________ endometrialAge

• Blood bloodDx Age diagnosed:_________ bloodAge

• Other otherDX(please specify): Age diagnosed:_________

___________________

22. During the past 30 days, have you used any prescription drugs not prescribed to you by a doctor?

• Yes

• No

1. How often do you currently use tobacco products including cigarettes, chewing tobacco, electronic vaping products, etc.? tobacco

• Everyday 1

• Somedays 2

• Not at all 3

Sleep

24. On average, how many hours of sleep do you get in a 24-hour period on days you are working? Think about the time you actually spend sleeping or napping, not just the amount of sleep you think you should get. hoursSleep

Hours:___________#  Don’t know 99

25. Is this sleep usually continuous or broken up? For example, if you had slept for 8 hours, was that 8 uninterrupted hours or was it broken up with work? contSleep

• Continuous 1

• Broken-up 2

2. (M3)- Wellsite Work

Training

1. In the past year, have you received training or information related to any of the following topics?

   Your job duties trainingA	Yes 1	No 2	Don’t know 99
   First aid traningB	Yes 1	No 2	Don’t know 99
   Use of personal protective equipment trainingC	Yes 1	No 2	Don’t know 99
   Emergency action plans trainingD	Yes 1	No 2	Don’t know 99
   Confined space trainingE	Yes 1	No 2	Don’t know 99
   Hazard recognition and assessment trainingF	Yes 1	No 2	Don’t know 99
   Hazard communication trainingG	Yes 1	No 2	Don’t know 99
   Stop work authority trainingH	Yes 1	No 2	Don’t know 99
   Safety data sheets trainingI	Yes 1	No 2	Don’t know 99
   Lock out/tag out procedures trainingJ	Yes 1	No 2	Don’t know 99
   Job hazard analysis trainingK	Yes 1	No 2	Don’t know 99
   Other trainings (please specify): trainingO _________________________

2. Do you think you were trained well enough to do your job safely?

• Yes 1

• No 2

• Don’t know 99

1. Have you ever received formal classroom training in SafelandUSA? safelandUSA

• Yes, 0-12 months ago 1

• Yes, 12+ months ago 3

• No 2

• Don’t know 99

Safety Culture

4. Does your company offer safety awards/incentives? awards

• Yes 1

• No 2

• Don’t know 99

1. Does your company offer production bonuses? productionBonus

• Yes 1

• No 2

• Don’t know 99

1. Have you or your crew ever not reported an injury/incident because it would prevent you from receiving a safety or injury free bonus? notReportInjury

• Yes 1

• No 2

• Don’t know 99

1. Does your company have a safety program, written policies, rules or guidelines regarding workplace safety? safetyProgram

• Yes 1

• No 2

• Don’t know 99

1. Does your company have a program for workers who are new to the oilfield, such as mentoring? shortService

• Yes 1

• No 2

• Don’t know 99

1. Does your company have a ‘Lone Worker’ program for the safety of workers who work alone? loneWorker

• Yes 1

• No 2

• Don’t know 99

1. Does your company have limits on the maximum amount of time that you can work in a day?

• Yes 1

• No 2  Go to 3.12.

• Don’t know 99

11. What is the maximum number of hours? _______ hours

12. In your current job, how often do you have to work beyond this maximum number of hours?

• Rarely/Never (once a year or less) 1

• A few times a year 2

• Monthly 3

• Weekly 4

• Several times a week 5

1. Does your company ever provide transport for crews to and from well sites in the area where your work?

• Yes 1

• No 2

• Don’t know 99

1. Does your company conduct daily task-specific Job Hazard Analysis/Job Safety Analysis or something similar? JSA

• Yes 1

• No 2

• Don’t know 99

15. What do you think about these statements relating to worker safety at your current company?

	Strongly Agree	Agree	No opinion	Disagree	Strongly Disagree
Safety is given a high priority by management	□	□	□	□	□
I feel that it is important to maintain safety at all times	□	□	□	□	□
I use the correct safety procedures for carrying out my job	□	□	□	□	□
I put in extra effort to improve the safety of the workplace	□	□	□	□	□

Personal Protective Equipment (PPE)

The following are a similar set of questions for several types of PPE.

Hardhat

1. Do you think you need a hardhat to do any of your job tasks? □ Yes 1 □ No 2

2. Does your employer require you to wear a hardhat to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with a hardhat? □ Yes 1 □ No 2

4. How often do you wear your hardhat when it is needed or required for safety? WearA

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4: Why? _____________

• Not needed for my job

Hearing Protection

1. Do you think you need hearing protection to do any of your job tasks? □ Yes 1 □ No 2

5. Does your employer require you to wear hearing protection to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

2. Does your employer provide you with hearing protection? □ Yes 1 □ No 2

3. How often do you wear hearing protection when it is needed or required for safety? WearB

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4: Why? _____________

• Not needed for my job

Gloves

1. Do you think you need gloves to do any of your job tasks? □ Yes 1 □ No 2

2. Does your employer require you to wear gloves to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with gloves? □ Yes 1 □ No 2

4. How often do you wear your gloves when it is needed or required for safety? WearC

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4 : Why? _____________

• Not needed for my job

Flame Resistant (FR) Clothing

1. Do you think you need FR clothing to do any of your job tasks?□ Yes 1 □ No 2

2. Does your employer require you to wear FR clothing to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with FR clothing? □ Yes 1 □ No 2

4. How often do you wear your FR clothing when it is needed or required for safety? WearD

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4: Why? _____________

• Not needed for my job

Fall Protection Equipment

1. Do you think you need fall protection equipment to do any of your job tasks?

□ Yes 1 □ No 2

2. Does your employer require you to wear fall protection equipment to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with fall protection equipment? □ Yes 1 □ No 2

4. How often do you wear your fall protection equipment when it is needed or required for safety? WearE

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4: Why? _____________

• Not needed for my job

3.16

Multi Gas Monitor (CO, O₂, LEL, H₂S)

1. Do you think you need a multi gas monitor to do any of your job tasks? □ Yes 1 □ No 2

5. Does your employer require you to wear a multi-gas monitor to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

2. Does your employer provide you with a multi gas monitor? □ Yes 1 □ No 2

3. How often do you wear your multi gas monitor when it is needed or required for safety? WearG

• Never: Why?  Go to 3.18. 1

• Some of the time 2

• Most of the time 3

• Always 4 Why? ___________

• Not needed for my job  Go to 3.18.

4. Did you receive training on your multi gas monitor? This would include information on calibration, what to do when it alarms, and the limitations. □ Yes 1 □ No 2

21. If you use a multi gas monitor at work, go to 3.20. Otherwise, please answer these questions about an H₂S monitor.

Hydrogen Sulfide (H₂S) Monitor

1. Do you think you need an H₂S monitor to do any of your job tasks? □ Yes 1 □ No 2

2. Does your employer require you to wear an H₂S monitor to do any of your job tasks? □ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with an H₂S monitor? □ Yes 1 □ No 2

4. How often do you wear your H₂S monitor when it is needed or required for safety? WearF

• Never 1: Why? _____________

• Some of the time 2

• Most of the time 3

• Always 4: Why? _____________

• Not needed for my job

Respirator

1. Do you think you need a respirator to do any of your job tasks? □ Yes 1 □ No 2

2. Does your employer require you to wear a respirator to do any of your job tasks?□ Yes 1 □ No 2

• I do think I need a hardhat and my employer does require me to wear a hardhat.

 Go to Next Question

• I do think I need a hard, but my employer does not require me to wear a hardhat.

 Go to 3.11.c

• I do not think I need a hard hat, but my employer does require me to wear a hardhat.

 Go to Next Question

• I do not think I need a hard hat and my employer does not require me to wear a hardhat.

 Go to 3.12

I prefer not to answer

 Go to 3.12

3. Does your employer provide you with a respirator or is there one available on site? □ Yes 1 □ No 2

4. How often do you wear your respirator when it is needed or required for safety? WearH

• Never: Why? _ Go to 3.21.:

• 1Some of the time 2

• Most of the time 3

• Always: Why? ____ 4

• Not needed for my job  Go to 3.19.

5. Are you clean shaven when you wear your respirator? Shave

• Never 1

• Some of the time 2

• Most of the time 3

• Always 4

6. What type of respirator were you provided or made available on site? (Check all that apply) TypeResp

• Half face 1

• Full face 2

• SCBA (Self-Contained Breathing Apparatus) 3

• Other 4

7. Have you been “fit-tested” for your respirator/s? □ Yes 1 □ No 2

8. Did you receive training on your respirator/s? This would include information on inspection, maintenance, and storage. □ Yes 1 □ No 2

On-the-job Injuries

24. During the past 12-months while working in the oilfield, did you receive any on-the-job injuries for which you had to see a doctor or other health care professional? Do not include injuries from car crashes, we will ask about that later in the survey. inj

• Yes1

• No2  Go to 3.22.

1. How many on-the-job injuries did you have during this 12 month period? injNum_________

2. What event or action caused the injury?

• Being struck by a motor vehicle or mobile equipment while not in a vehicle 1

• Caught in objects or equipment (i.e. pinch point) 2

• Exposure to gases or vapors 3

• Fall from height 4

• Fire 5

• Overexertion or repetitive motion or vibration 6

• Struck by objects or equipment 7

• Slip/Trip 8

• Violence or assault 9

• Other 97 (please specify): __________________________typeInjO

1. What were you doing when the injury incident occurred?

Task:_______________________________________________________________

2. Were you hospitalized due to this injury?

• Yes 1

• No 2 Go to 3.22

3. Did you miss any work due to this injury?

• Yes 1

• No 2  Go to 3.22

4. How much time were you away from work? Months ____ Weeks _____ Days ______

Chemical Products and Hazardous Substance Exposures

27. At work, do you handle or have skin contact with process fluids, chemical products, or substances?

• Yes 1

• No 2  Go to 3.30

• Don’t Know

28. How often do you handle or come in contact with these fluids, chemical products, fluids or substances?

• Daily 1

• Multiple times per day 2

• Two or more times per week

• Once a week

• Once a month or less

• Don’t Know

29. Have you received training through your company on the properly handling of chemicals that you work with?

• Yes 1

• No 2

30. Please list if you come in contact with the following products.

    1. Drilling Mud □ Yes 1 □ No 2

    2. Fracking Fluid □ Yes 1 □ No 2

    3. Flowback fluids □ Yes 1 □ No 2

    4. Crude Oil □ Yes 1 □ No 2

    5. Pipe Dope □ Yes 1 □ No 2

    6. Diesel Exhaust □ Yes 1 □ No 2

    7. Other: _________________________________

31. Rate your level of concern about contact with these products:

• No concern

• Slightly concerned

• Somewhat concerned

• Very concerned

32. What chemical hazards or substances are you most concerned about?

_______________________________________________________________________________

33. Are Safety Data Sheets (SDSs) for chemicals and substances workers are exposed to available to you?

• Yes 1

• No 2  Go to 3.30

• Don’t Know  Go to 3.30

1. Have you read the SDSs for the chemical products and substances you routinely work with?

• Yes 1

• No 2

1. At work, do you open tank hatches or work around open tanks at least twice a week or more?

• Yes 1

• No 2  Go to 3.35

1. Have you experienced any of the following symptoms while working around these products at work? (Check all that apply)

• Dizziness or lightheadedness

• Redness, dryness, itchy, watery eyes or blurred vision

• Nausea

• Headaches

• Redness, irritated, or scratchy skin

• Other skin discomfort

• Dry mouth

• Difficulty swallowing

• Fever or chills

• Fatigue

• Recurrent infections

• Weight loss without trying to lose weight

• Swollen lymph nodes

• Bruising or bleeding easily

• Bone Pain

• Pale Skin

• Prolonged Bleeding

• Rapid/irregular heart rate

1. Have you sought treatment at a clinic or emergency room?

• Yes 1

• No 2

Silica

38. Is sand used at your current worksite, such as for hydraulic fracturing?

• Yes 1

• No 2  Go to 3.36

• Don’t Know  Go to 3.36

1. How often is sand, such as for hydraulic fracturing, used while you are working?

• Daily

• A few times a week

• A few times a month

• Rarely

• Other: ________________________________

1. Have you received training or information on the hazards to exposure to silica dust from sand?

• Yes 1

• No 2

• Don’t Know

1. Has your current company implemented controls to limit your exposure to silica dust, such as requiring respirators while working around sand, using equipment that limits dust generation, or using policy or procedures to limit number of times or duration you are exposed to silica dust?

• Yes 1

• No 2

• Don’t Know

Dermatitis

42. During the past year, have you had dermatitis, eczema, or any other red, inflamed skin rash?

• Yes 1

• No 2  Go to 3.43

1. Have you had any of the following symptom(s) or problems? (Check all that apply)

• Redness

• Itching

• Scratch marks that come and go

• Peeling, cracking, scaling or flaking skin

• Bumps, blisters, or other lesions on skin

• Welts, hives, or swollen areas on skin

• None of these  Go to 3.39

1. What parts of your body were affected by this skin condition? (Check all that apply)

• Hands

• Arms

• Head/face/neck

• Legs

• Other: ________________________

1. Have you seen a doctor or other health care professional for your skin condition?

• Yes 1

• No 2  Go to 3.41

1. Were you told that the skin condition was probably work-related?

• Yes 1

• No 2

47. If you missed work due to a skin condition during the past year, how much time were you away from work?

Months ____ Weeks _____ Days ______

48. During the past year, did you stop working, change jobs, or make a major change in your work activities – such as taking on lighter duties – because of your skin condition?

• Yes 1

• No 2

49. On average, how much time do you spend in the sun per day during your typical work shift?

• Less than 1 hour

• 1 to 4 hours

• 4 to 7 hours

• 8 or more hours

50. Which of the following do you use when in the sun? (Check all that apply)

• Sunscreen

• A hat

• Long sleeve shirt

• None

3. (M4)- Motor Vehicle

   1. Do you drive a vehicle as part of your work duties?

• Yes 1

• No 2  Go to 4.1.

2. How long have you been driving as part of your work duties in the oil and gas industry?

____________ Years ___________ Months

3. Over the past 12-months, how many miles would you estimate that you have driven on the job?

• Less than 25,000

• 25,001-50,000

• 50,001-75,000

• 75,001-100,000

• 100,001-125,000

• 125,001-150,000

• 150,001-175,000

• 175,001-200,000

• Over 200,000

4. Do you currently have a commercial driver’s license (CDL)?

• Yes 1

• No 2

5. What is the type of vehicle you most often drive for work purposes?

• Passenger Car

• Light Truck (Weight less than 10,000 lbs)

• Van

• Single Unit Truck (10,001-19,500 lbs)

• Single Unit Truck (19,501-26,000 lbs)

• Single Unit Heavy Truck (greater than 26,000 lbs)

• Single Unit Truck (unknown weight)

• Medium/Heavy Pickup (i.e. Ford Super Duty 450/550)

6. In your current job, what do you haul with your vehicle? (Check all that apply)

• Crude oil

• Water

• Wastewater (brine)

• Equipment

• People

• Nothing

1. Do you collect fluid samples (thieve) or gauge tanks?

• Yes 1

• No 2  Go to 4.12

8. Do you open the thief hatch to collect samples (thieve) or gauge tanks?

• Yes 1  Go to 4.9

• No 2

9. How do you gauge or get your sample?

_________________________________________________________________________________

10. Have you experienced dizziness, disorientation or similar symptoms while collecting samples?

• Yes 1

• No 2

1. Do you use the following equipment while collecting samples? (Check all that apply)

• Respirator 1 Type: _________________________

• Hydrogen Sulfide Monitor 2

• Multi Gas monitor (CO, O₂, LEL, etc.)

12. How were you being paid for your driving time on your most recent trip?

• By the hour

• By the mile

• By the load

• A percentage of revenues

• Salary

• Other: ________________________________

13. Are you paid for non-driving work such as dropping and hooking trailers, waiting at the rig site, or loading/unloading/securing the load?

• Yes

• No

1. On your most recent trip, did your company offer bonuses or incur penalties based on whether or not you delivered your cargo on time?

• Yes

• No

15. How often do you feel very drowsy when you are driving at work?

• Never (or almost never)  Go to 4.17

• About once a month

• About once a week

• 2 or 3 times per week

• 4 or 5 times per week

• Almost every day

16. Keeping in mind that all of your responses are anonymous, have you ever nodded off or fallen asleep while driving your work vehicle?

• Yes

• No  Go to 4.19

17. How often do you estimate this has happened in the last 3 months?

• Not at all

• Only one or two times

• About once per week

• 2 or 3 times per week

• More than 3 times per week

18. In the last 2 days, have you used medications or drugs to help you stay awake while driving?

• Yes

• No

1. In your working career driving in the oilfield, have you ever been in a crash as a driver or passenger in which there was a death, injury requiring medical attention or a vehicle was towed?

• Yes

• No  Go to 4.26

20. As a driver or passenger, how many of these crashes have you had? _______________

21. In what calendar year was your most recent crash? Year ________

22. In your most recent crash, were you the driver or a passenger?

• Driver

• Passenger

1. In your most recent crash, did you receive any injuries that required immediate medical attention by a doctor, nurse, paramedic, or other health professional?

• Yes

• No  Go to 4.26

24. Did you miss any work days as a result of this injury?

• Yes

• No  Go to 4.26

1. How much time did you miss from work? __________ Weeks ___________ Days

2. In the past seven days, have you had a ‘near miss’ that made you feel lucky not to have been in a crash while driving your company vehicle?

• Yes

• No

27. How often do you do the following while driving your company vehicle?

	Always	Often	Sometimes	Rarely	Never
Get frustrated by other drivers on the road	□	□	□	□	□
Drive 10 or more miles per hour over the speed limit	□	□	□	□	□
Talk on handheld cell phone	□	□	□	□	□
Talk on hands free cell phone	□	□	□	□	□
Send text messages	□	□	□	□	□
Use cell phone for navigation or other uses	□	□	□	□	□
Eat	□	□	□	□	□
Wear a seatbelt	□	□	□	□	□

28. How many moving violations have you received while driving a company vehicle over the past 12-months? __________

29. Does your company have a vehicle safety policy?

• Yes

• No

• Don’t know

1. Does your current company have a policy that:

   	Yes	No	Don’t Know
   Bans hand held cell phone use while driving	□	□	□
   Bans hands free cell phone use while driving	□	□	□
   Bans texting while driving	□	□	□
   Requires seatbelt use at all times	□	□	□
   Requires drivers to conduct pre-trip vehicle inspections	□	□	□

2. Did you receive an orientation on vehicle safety when you were hired at your current job?

• Yes

• No  Go to 4.34

• Don’t know

1. Was the orientation specific to the type of vehicle that you drive?

• Yes

• No

33. Does your company require that you report:

	Yes	No	Don’t Know
Crashes	□	□	□
Near Misses	□	□	□
Vehicle Defects	□	□	□

34. Does your company require that your work vehicle be on a regular maintenance schedule?

• Yes

• No

• Don’t know

1. Does your company have a journey management policy? This policy would give you guidance on safe routes to take, how often to take breaks, and how to manage any other driving related risks.

• Yes

• No

• Don’t know

1. Does your company use in-vehicle monitoring systems? These systems track speeding events, harsh braking, and other driving behaviors.

• Yes

• No

• Don’t know

1. Does your company have a fatigue management policy?

• Yes

• No

• Don’t know

4. (M4)- Closing Questions

   1. Did you understand that your participation in the survey was voluntary?

• Yes

• No

1. Did you understand you could stop the survey at any time?

• Yes

• No

1. If you have any questions or concerns about the survey, do you know who you can contact?

• Yes

• No

1. Did you feel that you could be completely honest in your responses in this survey?

• Yes

• No

1. The information collected in this survey about oil and gas extraction workers will be used to help make workplaces safer and healthier. Any information we share will only include workers’ responses in groups so your individual responses are confidential and anonymous. In what ways do you think safety and health information should be shared with you and your coworkers? (Check all that apply)

• AM/FM Radio

• Pamphlets through your company

• Internet sites: _______________________

• Industry magazines: __________________

• Other: _____________________________

You are done!

Please take the survey to the researcher and answer 3 interview questions.

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[For Survey Staff]

Survey # __ __ __ __ Date ____________ Time of Day: __ __: __ __

Interview Location: State __ __ City ________________

□ Man Camp □ Equipment/Truck Yard □ Training Center □ Well Site

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing the 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 display 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).