App H_Survey for Recording Period for Boot Wear Evaluation (On-going)

Appendix H

Recurring Survey for Boot Wear Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Recurring Survey for Boot Wear Evaluation

Assigned participant ID: __________

Date: ____ / _____ / 20 _____

Recorded by: MFN / MEN / PD / WP / JP / AM / JM

Recording period: ___________

Photo of boots: Yes / No Scan of boots: Yes / No

Harris mat: Yes / No Hardness measure: ­­­­­­_________

1. Current job title (if it has changed): ______________________________
   
   
   

2. Total number of hours worked in the past two weeks: __________ hours
   
   
   

3. What shifts did you work in the past two weeks?

• Day

• Evening

• Night
  
  
  

4. Using the scale below, please rate your current level of comfort while wearing your work boots:

No discomfort 0 1 2 3 4 5 Intolerable Discomfort

5. Has there been any change in work tasks, locations or slip, trip, and fall history since your last survey?

□ If yes, please complete the remainder of the survey

□ If no, thank you for your time. This concludes this survey.

CDC estimates the average public reporting burden for this collection of information as 10 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

6. Locations where you worked most commonly, tasks you performed and approximate time spent at location

Location	Tasks performed	Approximate time spent at location

7. Did you slip, trip or fall in the past two weeks: Yes / No

• A slip is defined as simply a loss of traction of the foot; you can slip without falling. In general, if the foot slides, you have slipped. You might not have fallen even though you slipped.

• A trip is defined as something that prevents the foot from coming fully through its normal swing phase of the walking motion; you can trip without falling. In general, if the foot stops before making heel contact with the ground, you have tripped. You might not have fallen even though you tripped.

□ If Yes, Please provide the details for the slip, trip, or fall event(s) below

□ If no, thank you for your time. This concludes this survey.

Event 1:

1. Slip and fall / Slip without fall / Trip and fall / Trip without fall / Fall without slip or trip

2. Approximately when did the event occur: _______________________________________________

3. Where did the slip/trip/fall occur? ____________________________________________________

4. What was the weather like that day? __________________________________________________

5. What task/activity were you doing when you slipped/tripped/fell? __________________________

_________________________________________________________________________________

6. Was there any debris, contaminant or equipment/tools on the walking surface? Yes / No

If yes, what was on the walking surface?__________________________________________

7. Were you distracted or in a hurry? Yes / No

8. Were you carrying anything in your hands? Yes / No

If yes, what was in your hands? _________________________________________________

9. Describe the sequence of events leading up to the slip/trip/fall: _____________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Event 2:

1. Slip and fall / Slip without fall / Trip and fall / Trip without fall / Fall without slip or trip

2. Approximately when did the event occur: _______________________________________________

3. Where did the slip/trip/fall occur? ____________________________________________________

4. What was the weather like that day? __________________________________________________

5. What task/activity were you doing when you slipped/tripped/fell? __________________________

_________________________________________________________________________________

6. Was there any debris, contaminant or equipment/tools on the walking surface? Yes / No

If yes, what was on the walking surface?__________________________________________

7. Were you distracted or in a hurry? Yes / No

8. Were you carrying anything in your hands? Yes / No

If yes, what was in your hands? _________________________________________________

9. Describe the sequence of events leading up to the slip/trip/fall: _____________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Event 3:

1. Slip and fall / Slip without fall / Trip and fall / Trip without fall / Fall without slip or trip

2. Approximately when did the event occur: _______________________________________________

3. Where did the slip/trip/fall occur? ____________________________________________________

4. What was the weather like that day? __________________________________________________

5. What task/activity were you doing when you slipped/tripped/fell? __________________________

_________________________________________________________________________________

6. Was there any debris, contaminant or equipment/tools on the walking surface? Yes / No

If yes, what was on the walking surface? __________________________________________

7. Were you distracted or in a hurry? Yes / No

8. Were you carrying anything in your hands? Yes / No

If yes, what was in your hands? _________________________________________________

9. Describe the sequence of events leading up to the slip/trip/fall: _____________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________