Form 0920-21AN Non-respondent Questionnaire

Attachment 10. Non-respondent Questionnaire

Form Approved

OMB NO. 0920-xxxx

Expiration Date: xx/xx/20xx

Aviation Industry Workers Safety and Health Non-Respondent Survey

Will you answer a few short questions?

Yes continue to question 1

No EXIT survey

Thank you for agreeing to answer a few short questions for us.

1. How long have you worked for {pipe in company name}?

Please enter the number of months if less than 1 year.

• Years

• Months

2. What is the highest level of education you have completed?

• Less than high school

• Attended high school; didn't graduate

• GED or equivalent

• High school diploma

• Attended college; no degree

• Associate's degree

• Bachelor's degree

• Graduate or Professional degree

Public reporting burden of this collection of information is estimated to average 3 mins 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-xxxx).

3. Are you male or female?

• Male

• Female

• Prefer not to answer

4. How old are you?

• Years: ________________________________________________

• Prefer not to answer

5. What is your race?

Please select all that apply.

• American Indian or Alaska Native

• White

• Black or African American

• Native Hawaiian or Other Pacific Islander

• Asian

• Some other race. Please specify: ________________________________________________

• Prefer not to answer

Thank you for your help with this important survey.