Appendix I Pre-test screening

Heat-related Changes in Cognitive Performance

Appendix I Pre-test screening

OMB: 0920-1331

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Appendix I

Pre-test questionnaire






























Unique Id:


Date:


Emergency point of contact: (name & phone number):

_______________________________________________________

Shape1

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).




general health?

1. Do you feel well today O Yes O No

2. Have you had a cold or flu within the last two weeks? O Yes O No

(if no, skip to Question 4)

3. How long has it been since you recovered from the cold or flu? ______ days

4. Have you eaten today? O Yes O No

5. Have you had at least 8 ounces of fluid in the past four hours? O Yes O No

6. Have you started or stopped taking any medications, including vitamins, O Yes O No

supplements, herbal preparation/compounds, or naturopathic remedies (or

changed doses) since your last physical exam with our doctor

7. Take a few minutes to review the activity sheet(s) for the test you will be O Yes O No

performing today. Is there any reason why performing the tasks described may

be unsafe for you?

8. Have you had any illness or injury that required you to see a doctor or go to a O Yes O No

hospital for treatment since your last physical exam with our doctor?

9. Have you experienced any of the following conditions since your last

physical exam with our doctor?

O Shortness of breath

O Fainting or dizzy spells

O Wheezing

O Any other lung or heart problems

O Pregnancy (or possibility of pregnancy)

O Unusual, severe headaches

O Pain or tightness in your chest

O Numbness or tingling in extremities

O Irregular heartbeat

O Any musculoskeletal pain or discomfort

O High or low blood pressure

O Hemorrhoids

O Seizures


alcohol

During the past 24 hours, about how many alcoholic drinks did you drink?

(One drink is equivalent to a 12-oz beer, 5-oz glass of wine, or a drink with one shot of liquor).

___________ drinks


ACUTE diarrheal ILLNESS

Please check any illnesses you have had over the past 24 hours

O Nausea and vomiting

O Diarrhea

O Fever


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


_____________________________________________________________________________________



SLEEP

About what time do you think you fell asleep last night or earlier today? ______ AM / PM


About what time did you wake up today? ______ AM / PM


If you woke up in the middle of the night, how long were you awake? ______ Minutes

How would you rate your sleep quality overall last night?

O Very Good

O Fairly Good

O Fairly Bad

O Very Bad

HEALTH CONCERNS

Do you have any health-related concerns you want to discuss with our doctor prior to your participation in the study today?

O Yes O No

WORK CONDITIONS

In the LAST WEEK THAT YOU WORKED, how would you describe the air temperature in your work area?

O Very cold O Cold O Slightly cool O Neutral O Slightly warm O Warm O Hot O Very hot

In the LAST WEEK THAT YOU WORKED, how would you describe the humidity at your work area?

O Dry O Neutral O Humid

In the LAST WEEK THAT YOU WORKED, how would you describe the air circulation in your work area?

O Cold air flow O Cool air flow O No air flow O Warm air flow O Hot air flow

In the LAST WEEK THAT YOU WORKED , how much did you sweat, in general?

O I did not sweat O I sweat a little (i.e. armpits, face) O I sweat a moderate amount (armpits, face, chest, back) O I sweat a lot (clothes get completely wet)

In the LAST WEEK THAT YOU WORKED , how thirsty did you get?

O Not thirsty at all O I got thirsty occasionally O I got thirsty frequently O I was thirsty all the time

In the LAST WEEK THAT YOU WORKED, how hot did you get in your work area?

O Not hot at all O A little warm O Warm O Hot O Very hot

In the LAST WEEK THAT YOU WORKED, how physically fatigued were you at the end of your work day?

O Not tired at all O A little tired O Tired O Extremely tired

How many days have you worked in an area that you felt was warm or hot:

  1. In the past week? _________ days

  2. In the past 2 weeks? ________ days

In the PAST WEEK, how many days have you worked? __________ days

How many days ago was your last shift or work day? ___________ day(s) ago






Subject’s Signature ________________________________________


Resting Heart Rate ________________________________________


Resting Blood Pressure (Left or Right Arm) _________________________


Medical officer’s Signature ___________________________________________________




Pre-test USG __________ Post-test USG _________


Pre-test weight _________ Post-test weight________


Post-test Heart Rate ________ Post-test Blood Pressure _______


Post-test Core Temp ________ Body fat % _________

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorEllington, Jennifer (CDC/NIOSH/SMRD)
File Modified0000-00-00
File Created2021-09-04

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