NIOSH questionnaire

Attachment 2: Questions to be cognitively tested

Form Approved

OMB No. 0920-0222

Exp. Date: 08/31/2021

Notice – CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0222).

Assurance of Confidentiality – We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Questions for consideration for NHIS-OHS 2021 supplement

1. Does your employer deduct or withhold taxes from your pay?

a. Yes

b. No

Refused

Don’t know

2. Is the company that pays you at your main job a temporary help or staffing agency?

a. Yes

b. No

Refused

Don’t Know

*Read If Necessary: A temporary help or staffing agency is a company that supplies workers for temporary assignments to other companies or organizations.

3. Provided you wish to continue working, how long could you expect to have a job with your current employer? Would you say

a. 2 weeks or less

b. More than 2 weeks but less than 3 months

c. 3 months to less than 1 year

d. 1 year but less than 3 years

e. More than 3 years

Refused

Don’t Know

4. Which of the following best describes your usual hours of work on your main job?

a. Daytime shift

b. Evening shift

c. Night shift

d. Rotating shift

e. Some other shift

Refused

Don’t know

*Read if Necessary

Daytime – Most hours between 6 am and 6 pm

Evening – between 2pm and midnight

Night – Most hours between 9 pm and 8 am

Rotating – change periodically between day and evening shift, or between night shift and day or evening

5. How easy is it for you to change your work schedule to do things that are important to you or your family? Would you say…

a. Very easy

b. Somewhat easy

c. Somewhat difficult

d. Very difficult

Refused

Don’t know

6. Over the past 30 days, how many days did you work while physically ill?

1. ____ days

2. None

Refused

Don’t know

7. Over the past 30 days, how many mandatory hours of overtime did you work per week at your main job?

a. _____ hours per week

Refused

Don’t know

*Read If Necessary: By overtime, we mean work hours required by your employer that are over 40 hours per week.

8. How much do your earnings change from month to month? Would you say…

a. Not at all

b. A small amount

c. A moderate amount

d. A large amount

Refused

Don’t know

9.1 Does your work schedule at your main job change on a regular basis?

a. No (go to 10)

b. Yes (go to 9.2)

Refused

Don’t know

9.2 Approximately how far in advance does your employer usually tell you the hours that you will need to work on any given day?

a. 1 day or less

b. 2 to 3 days

c. 4 to 6 days

d. 1 to 2 weeks

e. 2 to 4 weeks

f. More than 1 month

Refused

Don’t know

Questions for consideration for future NHIS supplement if additional funding is received

10. Considering your performance at your main job, how fairly are you rewarded? Would you say…

a. Very fairly

b. Somewhat fairly

c. Somewhat unfairly

d. Very unfairly

Refused

Don’t know

11. On average, how often do you have to work an extra shift on short notice, that is within a day or less.

a. Never

b. Once a month or less

c. Two or three times a month

d. Once or twice a week

e. More than twice a week

Refused

Don’t know

12. Which statement best describes the number of hours you want to work?

a. I want to work more hours

b. I want to work fewer hours

c. I work about the right number of hours

Refused

Don’t know

13.1 Which of the following best describes how you are paid (in your main job)?

a. Salary (go to 13.2)

b. Hourly wage (go to 13.2)

c. Some other way (go to 13.3)

Refused

Don’t Know

13.2 Is there any other way that you are paid?

a. No (go to 14)

b. Yes (go to 13.3)

Refused

Don’t Know

13.3 What other way are you paid?

c. Commission or bonus

d. Tips

e. Based on the quantity of work you accomplish, such as the number of jobs, number of items, services, or sales

f. Profit from a business that you own

g. Other

Refused

Don’t know

14. During the past 12 months, which of the following statements best describes your home finances at the end of each month? With regard to money, do you have?

a. more than enough

b. just enough

c. not enough

d. much less than enough

Refused

Don’t know

15. Besides the employer who pays you, is there any other company or organization that also supervises you or directs how you do your job? (not asked)

a. No, my supervisors all work for the same employer who pays me

b. Yes, there is at least one person in another company or organization who supervises me

c. I do not have a supervisor

Refused

Don’t know

16. In my work, I feel alive and vital.

a. Strongly disagree

b. Somewhat disagree

c. Somewhat agree

d. Strongly agree

Refused

Don’t know

17.1 Which of these best describes your current work at your main job?

a. Employee of a PRIVATE company for wages (go to 17.2)

b. A FEDERAL government employee

c. A STATE government employee

d. A LOCAL government employee

e. Self-employed (go to 17.3)

f. Working WITHOUT PAY in a family-owned business or farm

Refused

Don’t Know

17.2 Do you work at a private for-profit or a private not for profit company?

a. Private for-profit company

b. Private not for profit company

Asked separately.

Refused

Don’t know

17.3 Do you own a business, professional practice or farm?

a. Yes

b. No

Refused

Don’t know

18. In your job, how often do your supervisors use electronic monitoring to keep track of what you do?

a. Not at all

b. A little

c. Somewhat

d. A lot

Refused

Don’t know

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