Attachment 2 Main Survey

Appendix 2: Main survey questions

In the main survey, participants will be randomly assigned to a reference period in the first screener item. Participants who respond negatively to the first screener item will be asked about injuries and illnesses in longer reference periods (12 months, 24 months) until they answer positively.

Welcome! Thanks for your interest in this study.

This study is part of our research to improve a survey on workplace injuries and illnesses.

The study should take about 10 minutes. Please only start the study when you will be able to complete the whole study without interruption. Please do your best to respond to the questions accurately.

Please do not use your browser's back button. 

This voluntary study is being collected by the Bureau of Labor Statistics under OMB No. 1220-0141 (Expiration Date: March 31, 2021). Without this currently-approved number, we could not conduct this survey. We estimate that it will take on average 10 minutes to complete this survey. Your participation is voluntary, and you have the right to stop at any time. This survey is being administered by SurveyMonkey and resides on a server outside of the BLS Domain. The BLS cannot guarantee the protection of survey responses and advises against the inclusion of sensitive personal information in any response. By proceeding with this study, you give your consent to participate in this study.

<page break>

We understand that some of the information we will ask about in this survey may be difficult to remember.

If you don’t remember something we ask about, then please select ‘I don’t remember’ instead of selecting an incorrect answer.

Please be honest – it is helpful for us to know if you had a hard time remembering something.

<page break>

1. Have you experienced any illnesses caused by an event or exposure while at work in the last [FILL: three months/twelve months/two years] since [FILL: MONTH YEAR]?
   Examples: Poisoning, skin disease, respiratory disorder
   Do not include the common cold or flu.

Yes

No

2. Have you experienced any injuries caused by an event or exposure while at work in the last [FILL: three months/twelve months/two years] since [FILL: MONTH YEAR]?
   Examples: Sprains, cuts, burns, bee stings

Yes

No

<page break>

If Q1 = No and Q2 = No then ask screener with next-longest reference period

3. Have you experienced any illnesses caused by an event or exposure while at work in the last [FILL: twelve months/two years] since [FILL: MONTH YEAR]?

Examples: Poisoning, skin disease, respiratory disorder
Do not include the common cold or flu.

Yes

No

4. Have you experienced any injuries caused by an event or exposure while at work in the last [FILL: twelve months/two years] since [FILL: MONTH YEAR]?
   Examples: Sprains, cuts, burns, bee stings

Yes

No

<page break>

If Q3 = No and Q4 = No then ask screener with next-longest reference period

5. Have you experienced any illnesses caused by an event or exposure while at work in the last two years since [FILL: MONTH YEAR]?

Examples: Poisoning, skin disease, respiratory disorder
Do not include the common cold or flu.

Yes

No

6. Have you experienced any injuries caused by an event or exposure while at work in the last two years since [FILL: MONTH YEAR]?
   Examples: Sprains, cuts, burns, bee stings

Yes

No

<page break>

If Q5 = No and Q6 = No then exit the survey

7. Thank you for your interest in the survey but you are not eligible to participate in this survey. You were invited to participate based on your responses from the initial screener survey from (FILL: DATES OF SCREENER SURVEY) in which you answered that you had had a workplace injury or illness in the last two years. Given your responses today – that you have not had a workplace injury or illness in the last two years – you are not eligible to participate.

<page break>

If Q1 = Yes or Q2 = Yes or Q3 = Yes or Q4 = Yes or Q5 = Yes or Q6 = Yes then

8. Please provide the approximate date of a workplace injury or illness from that time period.

Example: “May 2020”

[Date text entry]

9. Please provide a brief description of that workplace injury or illness.

Example: “carpal tunnel syndrome”

[Open text entry]

<page break>

10. Have you experienced any other injuries or illnesses caused by an event or exposure while at work in the last [FILL: reference period that triggered a “Yes” answer] since [FILL: MONTH YEAR]?

Examples: Fractures, punctures, bruises, burns, amputations, carpal tunnel syndrome, tendonitis, hernia, soreness, pain, hearing loss, glaucoma, migraine, stroke, cancer, fungal infection

Do not include the common cold or flu.

Yes

No

<page break>

If Q10 = Yes then

11. Please provide the approximate dates and brief descriptions of any other workplace injuries or illnesses from that time period.

You will not be asked any additional questions about these but we are interested in knowing what other workplace injuries or illnesses you had during that time period.

Example: “May 2020” and “carpal tunnel syndrome”

[Date text entry] [Open text entry]

[Date text entry] [Open text entry]

[Date text entry] [Open text entry]

[Date text entry] [Open text entry]

[Date text entry] [Open text entry]

<page break>

12. You reported more than one injury or illness. How did you decide to report on this one?

[FILL: Open text entry of injury or illness] from [FILL: Date text entry of injury or illness]

[Open text entry]

<page break>

13. Which of the following categories match the reason you gave? Select all that apply.

[FILL: Open text entry of reason for reporting this injury or illness]

It is the most severe injury or illness

It is the injury or illness that still affects my life the most

It is the injury or illness that I knew or remembered the most about

It is the most recent injury or illness

It is the most interesting injury or illness

It is the oldest injury or illness within the time period asked about

A different reason

<page break>

Now we have some follow-up questions about this injury or illness:

[FILL: Open text entry of injury or illness] from [FILL: Date text entry of injury or illness]

We are interested in understanding what you can remember about this injury or illness.

If you don’t remember something, then select “I don’t remember”.

If you remember all the details but prefer not to share the answer, then select “I prefer not to say”.

If you remember all the details but are not sure how to answer the question, then select “I don’t know”.

14. Did you receive care from a health care professional?
    Include care received immediately after the injury or illness occurred or as follow-up care at a later time.

Yes

No

I don’t remember

I prefer not to say

I don’t know

15. Did you take any time off work due to that injury or illness?
    Include time taken off for medical appointments.

Yes

No

I don’t remember

I prefer not to say

I don’t know

16. Were you ever assigned to a different job or tasks due to that injury or illness?

Yes

No

I don’t remember

I prefer not to say

I don’t know

<page break>

17. Still thinking of that work-related injury or illness -
    [FILL: Open text entry of injury or illness] from [FILL: Date text entry of injury or illness]
    What was your injury or illness? If you received a diagnosis, please include it in your description.
    Examples: carpal tunnel syndrome; strained back

[Open text entry]

What parts of your body were affected?
Examples: neck and back; lungs

[Open text entry]

What happened to cause the event or exposure?
Examples: when ladder slipped on wet floor, I fell 20 feet; struck by a paint can that fell of a shelf

[Open text entry]

What object or substance directly caused the injury or illness?
Examples: hitting the concrete floor; struck by a paint can; fumes from chlorine

[Open text entry]

<page break>

If Q14 (received medical care) = Yes

18. You reported receiving care from a health care professional for this injury or illness. Did the health care professional recommend any of the following due to your injury or illness? Select all that apply, even if you did not follow the recommendation.

Stay home from work

Reduce hours at work

Restrict work tasks

None of the above

I don’t remember

I prefer not to say

I don’t know

<page break>

If Q18 (healthcare recommendations) = Stay home from work

19. For how many calendar days did the health care professional recommend staying home from work?
    Report the number of recommended days, even if you did not follow the recommendation.
    Report calendar days, including weekends or days you were not scheduled to work.

Less than 1 calendar day

1 to 5 calendar days

6 to 10 calendar days

11 to 30 calendar days

More than 30 calendar days

I don’t remember

I prefer not to say

I don’t know

If Q18 (healthcare recommendations) = Reduce hours at work

20. For how many calendar days did the health care professional recommend reducing hours at work?
    Report the number of recommended days, even if you did not follow the recommendation.
    Report calendar days, including weekends or days you were not scheduled to work.

Less than 1 calendar day

1 to 5 calendar days

6 to 10 calendar days

11 to 30 calendar days

More than 30 calendar days

I don’t remember

I prefer not to say

I don’t know

If Q18 (healthcare recommendations) = restrict work tasks

21. For how many calendar days did the health care professional recommend restricting work tasks?
    Report the number of recommended days, even if you did not follow the recommendation.
    Report calendar days, including weekends or days you were not scheduled to work.

Less than 1 calendar day

1 to 5 calendar days

6 to 10 calendar days

11 to 30 calendar days

More than 30 calendar days

I don’t remember

I prefer not to say

I don’t know

<page break>

If Q15 (days away) = Yes

22. Did you return to work after the injury or illness?

Yes

Not yet, but I expect to return

No, I don't expect to return to any kind of paid work

I don’t remember

I prefer not to say

I don’t know

<page break>

If Q22 (return to work) = Yes or Q16 (job transfer) = Yes

23. How long was it until you returned to work?
    Report calendar days, including weekends or days you were not scheduled to work.

Returned to work the same day
Returned to work after 1 calendar day (the next day)
Returned to work after 2 to 5 calendar days
Returned to work after 6 to 10 calendar days
Returned to work after 11 to 30 calendar days
Returned to work after 30 calendar days
I don’t remember

I prefer not to say

I don’t know

24. When you went back to work, did you work fewer than your usual number of hours?

Yes

No

I don’t remember

I prefer not to say

I don’t know

25. When you went back to work, did you perform all of the normal duties of your job?

Yes

No

I don’t remember

I prefer not to say

I don’t know

26. When you went back to work, were you assigned a different job or tasks than what you did prior to the injury or illness?

Yes

No

I don’t remember

I prefer not to say

I don’t know

27. At any time AFTER you went back to work, did your injury or illness cause you to miss work?
    Include time taken off for medical appointments.

Yes

No

I don’t remember

I prefer not to say

I don’t know

<page break>

If Q25 (normal duties) = Yes or Q26 (job tasks) = Yes then

28. You reported that you did not do all of your normal job duties when you went back to work. For how long were your work activities restricted?
    Include light duty and transfers to other tasks
    Report calendar days, including weekends or days you were not scheduled to work.

Up to 1 calendar day

Up to 5 calendar days

Up to 10 calendar days

Up to 30 calendar days

More than 30 calendar days

I don’t remember

I prefer not to say

I don’t know

If Q24 (usual hours) = Yes then

29. You reported that you did not work your usual number of hours when you went back to work. In total, how many days of work did you miss due to your reduced work schedule?
    Report work days, that is, days you were scheduled to work.

Up to 1 day of work

Up to 5 days of work

Up to 10 days of work

Up to 30 days of work

More than 30 days of work

I don’t remember

I prefer not to say

I don’t know

If Q27 (miss work) = Yes then

30. You reported that, after you went back to work, your injury or illness caused you to miss more work. How much additional work time did you miss?
    Include time taken off for medical appointments.
    Report work days, that, is days you were scheduled to work.

Up to 1 day of work

Up to 5 days of work

Up to 10 days of work

Up to 30 days of work

More than 30 days of work

I don’t remember

I prefer not to say

I don’t know

<page break>

For the following questions, please consider the job at which you experienced the injury or illness.

31. What was your job title at the time of the injury or illness?
    Do not include any names or personal information.

[Open text entry]

<page break>

32. Which of the following occupation categories best matches your job ([FILL: Open text entry of occupation]) at the time of the injury or illness?

Management Occupations

Business and Financial Operations Occupations

Computer and Mathematical Occupations

Architecture and Engineering Occupations

Life, Physical, and Social Science Occupations

Community and Social Service Occupations

Legal Occupations

Educational Instruction and Library Occupations

Arts, Design, Entertainment, Sports, and Media Occupations

Healthcare Practitioners and Technical Occupations

Healthcare Support Occupations

Protective Service Occupations

Food Preparation and Serving Related Occupations

Building and Grounds Cleaning and Maintenance Occupations

Personal Care and Service Occupations

Sales and Related Occupations

Office and Administrative Support Occupations

Farming, Fishing, and Forestry Occupations

Construction and Extraction Occupations

Installation, Maintenance, and Repair Occupations

Production Occupations

Transportation and Material Moving Occupations

Military Specific Occupations

<page break>

33. What kind of business or industry did you work in at the time of the injury or illness?
    Examples: hospital, elementary school, residential or commercial construction, auto repair or auto sales, postal service, insurance, bank, retail sales, trucking or delivery, or a fast food restaurant.

[Open text entry]

<page break>

34. Which of the following industry categories best matches your job ([FILL: Open text entry of occupation]) at the time of the injury or illness?

Agriculture, Forestry, Fishing and Hunting

Mining, Quarrying, and Oil and Gas Extraction

Utilities

Construction

Manufacturing

Wholesale Trade

Retail Trade

Transportation and Warehousing

Information

Finance and Insurance

Real Estate and Rental and Leasing

Professional, Scientific, and Technical Services

Management of Companies and Enterprises

Administrative and Support and Waste Management and Remediation Services

Educational Services

Health Care and Social Assistance

Arts, Entertainment, and Recreation

Accommodation and Food Services

Other Services (except Public Administration)

Public Administration

<page break>

35. Which of the following best describes your employer at the time of the injury or illness?

Government
Private-for-profit company
Non-profit organization including tax exempt and charitable organizations
Self-employed
Working in the family business
I don’t remember

I prefer not to say

I don’t know

36. Which of the following best describes your employment type at the time of the injury or illness?

Independent contractor

Owner/Self-employed

Employee

I don’t remember

I prefer not to say

I don’t know

<page break>

37. Has a workers’ compensation claim been filed for this injury or illness?

Workers' compensation is insurance that provides you with your lost wages and medical care when you become injured or ill due to your job.

Yes

No

I don’t remember

I prefer not to say

I don’t know

<page break>

If Q37 (workers comp) = Yes then

38. Did you receive workers’ compensation for this injury or illness?

Yes

Claim is pending

No

I don’t remember

I prefer not to say

I don’t know

<page break>

Thank you for answering those questions about your workplace injury or illness.

Now we have a few questions for you about this survey.

39. Overall, how confident are you that the answers that you gave about your injury or illness are accurate?

Very confident

Somewhat confident

A little confident

I guessed

40. Was the injury or illness you reported ([FILL: Open text entry of injury or illness]) caused by an event or exposure while at work?

Yes

No

I don’t remember

I prefer not to say

I don’t know

41. If any of the questions did not seem to apply to your circumstances, please describe them here.

[Open text entry]

42. If any of the questions or instructions were confusing, please describe them here.

[Open text entry]

43. If you have any feedback about this survey, please enter it here.

[Open text entry]

<page break>

Thank you for your participation! Here is your completion code. Please paste this code into the HIT window to verify your participation.

[random numeric code]

Page 20 of 20