Form 0920-0260 HHE - Specific Interview Example

Page | 10 HHE#____

Form Approved

OMB No. 0920-0260

Exp. Date xx/xx/20xx

HHE Number:

Interviewer:

Date:

Name: __________________________________

Hello, my name is _______. I’m part of a team from the Centers for Disease Control and Prevention that is investigating (insert concern here) among employees at the (facility name). (Brief description of concern and why it is a concern.) We’d like to ask you some questions regarding your health, work, and activities that should help us learn more about worker exposures. It should take 15–20 minutes. Your individual responses will be used only for the purposes of this evaluation and will be kept strictly confidential. We will group your responses into summary results so your individual responses cannot be identified. Participation in this interview is voluntary; you may decline to answer any of the questions at any time.

Work history

I’d like to start by asking you some questions about your work.

1. What is your current job title?

2. What is your basic job description?

3. During a typical week, which building(s) or area(s) do you work in?

4. What is your primary work shift? (circle one)

First Second Third

Other (please explain, ask shift start and end times)

5. How many hours, on average, do you work a week at (facility name)? __________ hours per week

6. How long have you worked at (facility name)? _________ years ________ months

Public reporting burden of this collection of information is estimated to average 15 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 Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0260).

Work practices

The next questions deal with your usual work practices.

7. During your work day, how many hours, on average, do you spend

1. Walking to and from your car or van pool? _____ hours ____ minutes

2. Outdoors during gym or physical training (PT) time? _____ hours ____ minutes

3. Walking from building to building? _____ hours ____ minutes

4. Working outdoors? _____ hours ____ minutes

8. Do you eat outside while at work? Yes No

If yes, during your work day, how much time do you spend eating outside, on average?

_____ hours ___ minutes

9. What types of activities do you do when working outdoors? Check all that apply

□ Operate machinery If checked, please continue to question #10. Otherwise, go to question #11

□ Assemble or disassemble pallets

□ Load or unload materials onto trucks

□ Providing security at the gate

□ Patrol

□ Other, please specify

10. Only if “Operate machinery” was checked for question #9. Otherwise, go to question #11.

1. What type of machinery do you operate outdoors? Check all that apply

□ Forklift

□ Other, please specify

2. Does operating this machinery kick up dust? Yes No

3. Do you operate machinery with a closed or open cabin?

□ Open

□ Closed

□ Both

□ Not applicable

4. Do you use any respiratory protection? Yes No

If yes, what type?

11. Does your job involve being near activities that disrupt soil? Yes No

If yes,

1. How often you are near soil disruption activities at this facility?

Constantly Sometimes Rarely

2. Where is/were the soil disruption activities?

3. What types of soil disruption activities?

4. What types of equipment were being used?

5. Do you use any respiratory protection when you work near soil disrupting activities?

Yes No

If yes, what type(s)?

12. What building do you primarily work in?

1. When working indoors in this building, how often are the doors or bays open to the outdoors?

□ Constantly

□ Sometimes

□ Never

□ Not applicable (please explain)

If constantly or sometimes, were the doors or bays only open because it was necessary for work activities? Yes No Not sure

13. Do you work with materials that are dusty from being outside? Yes No Not sure

14. Before this interview started, had you ever heard of (hazard or disease)? Yes No

15. Since you started working at (facility name), have you ever received training on (hazard or disease) that might relate to your work here? Yes No

If yes, Please describe the type of training and who provided it:

16. Do you currently have access to an N95 respirator or other respirator?

Yes No

17. Have you ever used an N95 respirator or other respirator when exposed to dust during your work here? Yes No

If yes,

1. Was respirator use required or voluntary? (circle one)

Required Voluntary Other (please explain)

2. Please list the instances when you have used one:

3. What type of respirator have you worn? Check all that apply.

□ NIOSH-approved filtering facepiece respirator (N95)

□ Other, please describe:

4. In the last year,

1. Did you have medical evaluation to be cleared for using a respirator?

Yes No Not sure

2. Did you have respirator fit testing? Yes No Not sure

3. Did you have training on respirators? Yes No Not sure

Other Exposures

18. Outside of work, how many hours, on average, do you spend outdoors each day?

_______ hours _______ minutes

19. Regarding your activities, which of the following do you do regularly?

1. Gardening Yes No

2. Hiking/walking/running Yes No

3. Golfing Yes No

4. Biking Yes No

5. Other outdoor activity Yes No

If yes, specify: __________________________

Residence history (skip if no geographical impact on hazard or disease)

I’d like to ask you some questions about your place of residence.

20. What town or city do you currently live in? ________________________

21. Please list all of the places you have lived (city, state) in California, Nevada, Arizona, New Mexico, Utah, Texas, and Mexico and the length of time lived there. Work backwards in time.

City	State	Length of time (years, months)

Medical History

I’d like to ask you some questions about your health.

22. Do you have any of the following medical conditions? (check all that apply)

 Cancer requiring chemotherapy or radiation therapy

 Any disease that suppresses the immune system, including HIV or AIDS

 Lung disease, including asthma, COPD, emphysema, or other lung disease

 Diabetes mellitus

 Heart disease

 Solid organ transplant

 Bone marrow transplant

 Liver disease

 Kidney disease

23. Are you taking any medications that suppress your immune system (e.g., prednisone, cyclosporine, methotrexate)? Yes No

24. Do you currently smoke tobacco? Yes No

Illness history

25. Have you ever been diagnosed with (disease of concern)? Yes No

If no, go to next question (#26).

If yes, ask the following

a. When did your symptoms start? mm /dd /yyyy

i. Was this before or after you started working at (facility)?

Before After Not sure

b. How long did you live in the (area) before your diagnosis? ________ years

c. Were you told that you had disseminated disease (spread out in the body)?

Yes No Not sure

d. Did you have

i. skin lesions Yes No Not sure

ii. bone or joint infection Yes No Not sure

iii. meningitis Yes No Not sure

(swelling/inflammation of tissue surrounding the brain and spinal cord)

5. Were you hospitalized because of (disease of concern)? Yes No

6. How many days were you absent from work as a result of (disease of concern)? ____________ days

7. Did you report this illness to your employer? Yes No

Demographics

26. What is your date of birth? mm______/dd______/yyyy______

27. What is your sex? Female Male Other

If female: are you currently pregnant? Yes No Not sure

28. How would you describe your race? (Check or circle as appropriate)

American Indian or Alaskan Native

Asian

If Asian, are you Filipino? Yes No

Black or African American

Native Hawaiian or other Pacific Islander

White

Other, specify: ____________________

29. Are you Hispanic/Latino? Yes No

30. Do you have any other health or safety concerns related to your work here?

_____________________________________________________________________________________

_____________________________________________________________________________________

Thank you for participating in this interview. Depending on what we find out when we put these interviews together, we may need to follow up about a few details. Is there a phone number and e-mail address we may have in case we need to reach you?

Phone number: ( ) ______-__________

E-mail address: _________________________

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