Specific Worker Questionnaire - example

Health Hazard Evaluations/Technical Assistance and Emerging Problems

Attachment F

HHE Specific Worker Questionnaire (Example)

OMB: 0920-0260

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Attachment F

Sample HHE Specific Worker Questionnaire













































OMB No. 0920-0260

Expires xx/xx/xxxx





















Health Hazard Evaluation 2015-0148

Fort Rapids Indoor Waterpark and Resort January 2016





Shape1

Public reporting burden for this collection of information is estimated to average 10 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).





Study ID Number:

Age: ­ years

If <18 years old, has a parent/guardian given permission to participate?

Yes Continue

No STOP



Work history/practices

  1. What is your job title at Fort Rapids?

  2. How long have you worked at Fort Rapids? years months

  3. Do you work at Fort Rapids year-round or seasonally?

Year-round

Seasonal If seasonal, which months?


  1. In the past 4 weeks, how many days did you work at Fort Rapids? ­­____ days

  2. In the past 4 weeks, how many hours did you work at Fort Rapids? hours in the past 4 weeks

  3. In the past 4 weeks, how many hours did you work at Fort Rapids in a typical day? hours

  4. In the past 4 weeks, which locations did you work in? Please check all that apply.

Waterpark (including pump room)

Gift shop

Spa

DB’s Sidewinder Café

Hotel

Copper Star Saloon

Conference center

Canyon Café

Arcade

Other, please specify: _______________________



  1. In the past 4 weeks, how many hours did you spend in the waterpark (including the water attractions, DB’s Sidewinder Café, and pump room) on a typical work day? hours

If zero hours (i.e., you did not spend any time in the waterpark), please

skip to the Symptoms section on p. 3 (Question #14)




  1. In the past 4 weeks, how many of the following shifts did you work?


Number of shifts

Friday (3:30 pm to 9:30 pm)

______

Saturday AM (9:30 am to 3:30 pm)

______

Saturday PM (3:00 pm to 9:30 pm)

______

Sunday (9:30 am to 6:30 pm)

______

December weekday AM (9:30 am to 3:30 pm)

______

December weekday PM (3:00 pm to 9:30 pm)

______

Other, please specify times: ______________

______



  1. In the past 4 weeks, which rotations did you work? Please check all that apply.

Standing

Water

Tower

T3’s


  1. On the days that you worked in the past 4 weeks, how many hours per day did you usually spend in the water? hours


  1. In the past 4 weeks, did you handle vomit, stool, or blood in the water?

Yes

No


  1. In the past 4 weeks, did you mix or handle the chemicals used in the water?

Yes If yes, which chemicals?

No



Symptoms

  1. In the past 4 weeks, did you have any of the following symptoms that started while you were at work at Fort Rapids? Please do NOT include those associated with a cold or respiratory infection. Please check all that apply.

Symptom



Did the symptom get better when you were away from work?


Check if Yes


Yes

No

Cough

If yes, answer

Wheezing or whistling in the chest

If yes, answer

Unusual shortness of breath

If yes, answer

Chest tightness

If yes, answer

Nose irritation (i.e. burning, runny, or stuffy nose)

If yes, answer

Eye irritation (i.e. watery, red, or burning eyes)

If yes, answer

Sore throat

If yes, answer

Fever

If yes, answer

Body aches

If yes, answer

Nausea

If yes, answer

Vomiting

If yes, answer



If you did not check any symptoms in Question #14, please skip to Question #16.

  1. In the past 4 weeks, on how many work days did you experience symptoms in Question #14?

­ days


  1. In the past 4 weeks, have you had a skin rash?

Yes

No


16a. If yes, on which area(s) of the body was the rash? Please check all that apply.

Face

Neck

Hands

Arms

Legs

Chest

Other, please specify:



16b. If yes, how many days did the rash last? days

16c. If yes, do you think the rash was related to work?

Yes

No



If yes, why?

If you did not have any symptoms in Questions #14 and #16, please skip to the Medical History section (Question #19)


  1. In the past 4 weeks, have you taken time off from work for any of the symptoms listed in questions #14 and #16?

□ Yes

No



17a. If yes, how many days? days



  1. In the past 4 weeks, have you seen a doctor or other health care provider for any of the symptoms listed in questions #14 and #16?

Yes

No



18a. If yes, what did the doctor or provider say that you had?

Medical History

  1. Do you wear contact lenses while at work?

Yes

No


  1. Has a doctor or other health care provider ever told you that you have asthma?

Yes Please continue to answer 20 (a) to (c) below

No Skip to Question #21


20a. Did you have asthma before you started working at Fort Rapids?

Yes

No


20b. How old were you when you were diagnosed with asthma? ­ years old

20c. Do you still have asthma?

Yes Please continue to answer (i)-(ii) below

No Skip to Question #21


      1. Does your asthma seem worse when you are at work? □ Yes □ No

      2. Do you take any medications for your asthma? □ Yes □ No

If yes, what medications do you take?



  1. Do you have any of the following medical conditions?

    Hay fever or other seasonal allergies

    (do NOT include allergies to medications)

    Yes

    No

    Eczema or atopic dermatitis

    Yes

    No

    Chronic obstructive pulmonary disease (COPD)/emphysema

    Yes

    No




  2. Please describe your cigarette smoking history. Please check one.

Never smoked (smoked less than 100 cigarettes [about 5 packs] in your entire life)

Former smoker

Current smoker


Demographics

  1. What is your sex?

Male

Female


  1. Phone:

  2. Email:

  3. Do you have any other health concerns related to your working at Fort Rapids? __________________________________



Thank you for participating in this questionnaire.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorChiu, Sophia (CDC/OPHSS/CSELS)
File Modified0000-00-00
File Created2021-01-22

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