Form 0920-0260 Specific Worker Questionnaire - example

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



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?

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

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

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

7. 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: _______________________

8. 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)

9. 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: ______________	______

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

□ Standing

□ Water

□ Tower

□ T3’s

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

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

□ Yes

□ No

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

□ Yes If yes, which chemicals?

□ No

Symptoms

14. 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.

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

­ days

16. 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)

17. 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

18. 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

19. Do you wear contact lenses while at work?

□ Yes

□ No

20. 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?

21. 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

22. 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

23. What is your sex?

□ Male

□ Female

24. Phone:

25. Email:

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

Thank you for participating in this questionnaire.