App I_Final Survey for Boot Wear Evaluation

Appendix I

Final Survey for Boot Wear Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Final Survey for Boot Wear Evaluation

Assigned participant ID: __________

Date: ____ / _____ / 20 _____

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

Picture of boots taken: Yes / No Scan of boots taken: Yes / No

1. What is your reason for ending this study?

 My company decided that I needed to replace my boots.

 This is the normal time for company-wide/site wide/crew wide replacement

 I decided I no longer wanted to participate.

 I decided that the boots had reached the end of their usable life

 How did you decide the boots had reached the end of their usable life?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Were your boots returned to the researcher? Yes / No

3. If you had a choice of wearing this exact make and model of boot again, would you?

 Yes, I hope to get these boots again.

 Yes, I would wear them again.

 No, I would not wear them again.

 Please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CDC estimates the average public reporting burden for this collection of information as 5 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).