Att D_ Non Respondent Questionnaire

Attachment D

Oil and Gas Workers Safety and Health Non-Respondent Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Thank you for agreeing to answer a few short questions for us.

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 the well-site for at least 2 days per week or more? ☐Yes ☐No

3. What type of company do you work for?

☐ Drilling contractor ☐ Well servicing company

☐ Operator ☐ Other _________________________

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

☐Yes ☐No

5. What is your

• Age: _____ years

• Sex: ☐ Male ☐ Female

• Race: ☐ White ☐ Black or African American

☐ American Indian or Alaska Native ☐ Asian

☐ Native Hawaiian or Pacific Islander

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

☐Yes ☐No

Thank you for your help with this important survey.

Public reporting burden of this collection of information is estimated to average non-respondent questionnaire is 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).

[For Survey Staff]

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

Interview Location: State __ __ City ________________

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