Appx E - Heat stress app - post-shift questionnaire (field) (M)

Appendix E Post-shift questionnaire on heat stress app

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Post-shift questionnaire:

1. Which shift are you currently working? (daytime, evening, night, other)

2. How many days in a row have you worked so far during your current shift cycle? (Please include the shift that you are about to start today).

3. During the past 24 hours, about how many alcoholic drinks did you drink? (one drink is equivalent to a 12-ounce beer, 5-ounce glass of wine, or a drink with one shot of liquor).

4. Please check any illnesses you have had in the past 24 hours: (nausea and vomiting; fever; diarrhea; upper respiratory infection (cough, runny nose, congestion), none).

5. Please list any medications (including over the counter) that you are taking for this illness. _____

6. About what time do you think you fell asleep last night or earlier today?

7. About what time did you wake up today?

8. If you woke up in the middle of the night, how long were you awake?

9. How would you rate your sleep quality overall last night? (very good, fairly good, fairly bad, very bad)

10. Please mark any symptoms you noticed during your shift (nausea, vomiting, chills, dizziness/lightheadedness, headache, irritability, confusion, excessive fatigue, excessive thirst that was not easily quenched, muscle cramps or spasms, muscle weakness, decreased urine output or dark colored urine, profuse sweating)

11. Since the beginning of your shift, have you slowed your work rate or taken a short break because you were starting to feel hot or tired? Yes/No (if yes: ___ times, ____ minutes per break)

12. Please indicate what you have been drinking during this shift (water, soda, diet soda, energy drinks, sports drinks, coffee, other)

13. Please indicate which work tasks you just completed, starting with the most recent:

Task _________

What time did you start this work task? _______

What time did you end this work task? _______

Describe your exertion level during this task

14. In the past week at work, how would you describe the air temperature in your work area? (very cold, cold, slightly cool, neutral, slightly warm, warm, hot, very hot)

15. In the past week at work, how would you describe the humidity in your work area? (dry, neutral, humid)

16. In the past week at work, how much did you sweat in general? (did not sweat, a little in armpits and face, a moderate amount in armpits, face, chest, back, a lot with clothes getting wet)

17. In the past week at work, how hot did you get in your work area? (not hot at all, a little warm, warm, hot, very hot)

18. In the past week, how many days have you worked in an area that you felt was warm or hot? ___ days

19. In the past week, how many days have you worked? ___ days

20. Women only: Last menstrual period ______

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).

Heat stress app screen shots