Form 0920-0260 HHE Specific Questionnaire Example

ID #: ________ Date: __ __ / __ __ / __ __ __ __ PO initials: _______ HHE XXXX-XXXX

Form Approved

OMB No. 0920-0260

Exp. Date xx/xx/20xx

U. S. Department of Health and Human Services

U. S. Public Health Service

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Health Hazard Evaluation #

Facility Name

This questionnaire is part of a National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation (HHE) of (hazard of concern) at the (facility name). (Insert short summary of HHE request.) This questionnaire includes questions about work practices, training, policies and procedures, and any health or safety concerns.

Participation in this HHE and completion of this questionnaire are voluntary – there is no penalty for choosing not to participate. However, full participation will better enable NIOSH to assess exposures and health among employees at your workplace.

Please answer all questions to the best of your ability. If you don’t understand any questions, please ask for assistance. All personal information from this questionnaire will be kept confidential according to federal law. Group summary results of this evaluation (without any personal identifying information) will be provided to employees, union representatives, and management in the form of a final report that will be prepared after the survey is complete.

Thank you for your time and effort in filling out this questionnaire.

Public reporting burden of this collection of information is estimated to average 30 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 (0920-0953).

Section 1: Work History and Practices –

We will start by asking some questions about your work.

1. Which department do you work in?

2. How long have you worked for the (facility name)?

­ years and months OR ______________ start date

3. How many total hours have you worked over the past two weeks? _____ total hours over 2 weeks

3a. How many hours have you worked inside the (area of concern) over the past two weeks? _____ hours over 2 weeks

4. What is your job title? (Please check ONLY ONE response)

☐ Job Title 1

☐ Job Title 2

☐ Job Title 3

☐ Job Title 4

☐ Other (please specify: ___________________________________________________)

5. About how many samples did you handle over the past two weeks? _______ samples

6. Did you work with (exposure of concern) over the past two weeks? (Please check all that apply)

☐ Exposure 1

☐ Exposure 2

☐ Exposure 3

☐ Exposure 4

☐ Other (please specify: ____________________________________________________)

☐ Don’t know

7. If applicable, how many (job task of concern) did you perform over the past two weeks?

_______ (job tasks)

☐ I did not (perform job task of concern)

8. Do you ever (perform job task of concern) under a ventilation fume hood?

☐ No à IF NO, SKIP TO QUESTION #9.

☐ Yes à IF YES, ANSWER QUESTIONS #8a–8b.

If yes,

8a. How many (job task of concern) did you perform under a ventilation fume hood over the past two weeks? _______ (Job tasks)

8b. How do you determine which (job tasks to perform) under a ventilation fume hood?

________________________________________________________________________

________________________________________________________________________

9. Over the past two weeks, how often have you used the following when handling (hazard of concern):

Personal Protective Equipment (PPE)	Frequency of Use
	Always	Sometimes	Never
Latex or nitrile gloves?	☐	☐	☐
Lab coat? (specify type:______________________)	☐	☐	☐
Eye protection? (specify type: ________________)	☐	☐	☐
Mask or Respirator (e.g., cloth mask, procedure mask, KN95, or N95 respirator)?	☐	☐	☐
Other PPE? (specify type:____________________)	☐	☐	☐

If you used latex or nitrile gloves at work over the past two weeks,

9a. How often did you change your gloves over the past two weeks?

☐ After every job task

☐ Several times a day but not after every job task

☐ Once a day

☐ Other (specify: ________________________________________________________)

9b. How often did you wash your hands after removing your gloves over the past two weeks?

☐ Every time

☐ Sometimes but not after every glove removal

☐ Never

☐ Other (specify: ________________________________________________________)

9c. Did you receive training or written policies and procedures from (facility name) on when to wear gloves and how often you should change your gloves?

☐ Yes à IF YES, ANSWER QUESTION #9c,i.

☐ No

☐ I don’t know

9c,i. What is your understanding of the policy on when to wear gloves and how often you should change your gloves?

______________________________________________________________________________

______________________________________________________________________________

If you used a lab coat at work over the past two weeks,

9d. How often did you change your lab coat over the past two weeks? (i.e., used a new disposable lab coat or a newly laundered lab coat)

☐ Several times a day

☐ Once a day

☐ Less than once a day

☐ Other (specify: ________________________________________________________)

9e. When was your lab coat last laundered? ____/____/______ OR ☐ Not Applicable

(mm) (dd) (yyyy)

9f. Did you receive training or written policies and procedures from (facility name) on when to wear a lab coat and how often you should change or launder your lab coat?

☐ Yes à IF YES, ANSWER QUESTION #9f,i.

☐ No

☐ I don’t know

9f,i. What is your understanding of the policy on when to wear a lab coat and how often you should change or launder your lab coat?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If you used eye protection at work over the past two weeks,

9g. Why did you wear eye protection over the past two weeks?

☐ Personal preference

☐ Required for specific job duties (specify:

☐ Other (specify: ________________________________________________________)

9h. Did you receive training or written policies and procedures from (facility name) on when to wear eye protection?

☐ Yes à IF YES, ANSWER QUESTION #9h,i.

☐ No

☐ I don’t know

9h,i. What is your understanding of the policy on when to wear eye protection?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If you used a mask or respirator at work over the past two weeks,

9i. Select what masks/respirators you have worn over the past two weeks: (check all that apply)

KN95 N95

☐ Cloth mask ☐ Disposable/surgical mask ☐ KN95 mask ☐ N95 respirator

☐ Other/not listed (please specify: ________________________________________________)

9j. For each type of mask or respirator you have worn over the past two weeks, why did you wear it?

Mask or respirator type	I did not wear at work in the past 2 weeks	Personal preference	Specific job duties (if any are checked, answer question 9j,i)	Other (please specify)
Cloth mask	☐	☐	☐
Disposable/surgical mask	☐	☐	☐
KN95 mask	☐	☐	☐
N95 respirator	☐	☐	☐
Other type of mask	☐	☐	☐

If you used a mask or respirator for specific job duties, please answer the following question:

9j,i. For each type of mask or respirator you have worn over the past two weeks, what job activities did you use a mask or respirator for?

Mask or respirator type	Job activities
Cloth mask
Disposable or surgical mask
KN95 mask
N95 respirator
Other type of mask or respirator

9k. For each type of mask or respirator you have worn over the past two weeks, how often did you change your mask/respirator?

Mask or respirator type	I did not wear at work in the past 2 weeks	After every case	Several times a day but not after every case	Once a day	Other (please specify in the space below)
Cloth mask	☐	☐	☐	☐
Disposable or surgical mask	☐	☐	☐	☐
KN95 mask	☐	☐	☐	☐
N95 respirator	☐	☐	☐	☐
Other type of mask or respirator	☐	☐	☐	☐

9l. Have you been medically cleared to wear a respirator in the past 12 months?

☐ Yes ☐ No ☐ I don’t know

9m. Have you had respiratory fit testing in the past 12 months?

☐ Yes ☐ No ☐ I don’t know

9n. Did you wear a respirator over the past two weeks for which you passed fit testing?

☐ Yes ☐ No ☐ I don’t know

9o. For each type of mask/respirator you have worn over the past two weeks, where did you store your mask/respirator over the past two weeks?

☐ I used disposable masks/respirators that were discarded after use

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

9p. Did you receive training or written policies and procedures from (facility name) on when to wear a mask or respirator?

☐ Yes à IF YES, ANSWER QUESTION #9p,i.

☐ No

☐ I don’t know

9p,i. What is your understanding of the policy on when to wear a mask or respirator?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

10. Over the past two weeks, how often have you been in the lab without any PPE? Masks for protection against COVID-19 are not considered PPE.

☐ Never à IF NEVER, SKIP TO QUESTION #11.

☐ 1-2 times

☐ 3-5 times

☐ More than 5 times

10a. Why were you in the lab without PPE?

☐ Not handling samples or performing an experiment

☐ Quickly doing some work

☐ Other reason (specify: ___________________________________________________

________________________________________________________________________

11. Over the past two weeks, how often did you eat, drink, or store food or drink in the (area of concern)?

☐ Always

☐ Sometimes

☐ Never

12. Over the past two weeks, how often did you wash your hands immediately before or after leaving the (area of concern)?

☐ Always

☐ Sometimes

☐ Never

13. Over the past two weeks, how often did you wash your hands immediately before eating or drinking at work?

☐ Always

☐ Sometimes

☐ Never

14. Over the past two weeks, did you help clean in the (area of concern)?

☐ No à IF NO, SKIP TO QUESTION #15.

☐ Yes à IF YES, PLEASE ANSWER QUESTIONS #14a–14d.

If yes,

14a. What parts of the (area of concern) did you clean? (Please check ALL that apply)

☐ Area 1 à IF CLEANED Area 1, answer question 14a,i.

☐ Area 2

☐ Area 3

☐ Area 4

☐ Area 5

☐ Other (specify: ____________________________________________________________)

If you cleaned Area 1,

14a,i. How often did you clean (Area 1)?

☐ After every case

☐ Several times a day but not after every case

☐ Once a day

☐ Several times a week

☐ Weekly

☐ Less often than weekly

14b. What type(s) of cleaning activities did you do in the (area of concern)? (Please check ALL that

apply)

☐ Dry sweep floors

☐ Clean surfaces with dry cloth

☐ Clean surfaces with wet cloth/paper towel

☐ Other (specify: ________________________________________________________)

14c. What type(s) of cleaning solutions did you use in the (area of concern)? (Please check ALL that apply)

☐ Water

☐ Disinfectant wipes

☐ Bleach

☐ Lysol

☐ Ethanol

☐ Methanol

☐ Other (specify: ________________________________________________________)

14d. Does (facility name) provide direction on what cleaning solutions to use?

☐ Yes à IF YES, ANSWER QUESTION #14d,i.

☐ No

☐ Other (specify: ________________________________________________________)

14d,i. What is your understanding of what cleaning solution to use and when to use it?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Section 2: Training – Now we are going to ask some questions about training you may have received while working with the (facility name).

15. Have you received training about any of the following? If so, please provide an approximate month and year for when you last received this training.

Training	Yes	No	Date (mm/yyyy)	Not applicable to my work
Task 1	☐	☐		☐
Task 2	☐	☐		☐
Task 3	☐	☐		☐

15a. Do you feel training on any of these topics needs to be improved? ☐ Yes ☐ No

If yes, training on which topics need improvement and how would you suggest improving it?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Section 3: Incidents and Symptoms – Now we are going to ask some questions about any work-related incidents or symptoms that may have occurred over the past two weeks.

INCIDENT/SYMPTOM-RELATED QUESTIONS

16. In the past two weeks, have you had direct skin, respiratory, or mucous membrane exposure (e.g., eye or mouth) to (hazard of concern)?

☐ No à IF NO, SKIP TO QUESTION #17.

☐ Yes à IF YES, PLEASE ANSWER QUESTIONS #16a–16d.

If yes,

16a. How many times? ________ incidents

16b. Briefly describe the incident(s), including the specific (hazard of concern) you were working with when the incident occurred. ________________________________________________________________________

________________________________________________________________________

16c. If you had any symptoms after the incident, please briefly describe them:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

☐ □ I did not have any symptoms

16d. Did you report this incident?

☐ No à IF NO, ANSWER #16d,i.

☐ Yes à IF YES, SKIP TO QUESTION #17.

If no,

16d,i. Why not? ____________________________________________________

__________________________________________________________________

QUESTIONS ABOUT SYMPTOMS OR HEALTH EFFECTS

17. Have you ever experienced any of the following symptoms or health effects that you feel are related to handling cases/samples at work during your time as a (facility name) employee?

Symptom/Health Effect	Yes (if any are checked, go to Question 17a)	No	Not sure (if any are checked, go to Question 17a)
Feeling of increased heart rate
Trouble breathing
Stopped breathing
Nausea/vomiting
Increased sweating
Weakness (specify body part affected):
Tremor
Dizziness/lightheadedness
Numbness/tingling (specify body part affected):
Headache
Confusion
Loss of consciousness
Told by someone that your pupils were small (pinpoint)
Other symptoms (specify):

If you answered yes or not sure (grey boxes) to any symptom(s) or health effect(s) in question 17, please answer questions #17a–17f. Otherwise, skip to question #18.

17a. When did your symptom(s) occur? _______ (month) ________ (year)

If multiple symptoms, please list when each symptom occurred: _________________________

______________________________________________________________________________

______________________________________________________________________________

17b. How many times have you experienced the symptom(s)?

☐ Once

☐ More than once

If multiple symptoms, please list how many times you have experienced each symptom:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

17c. What were you doing when your symptom(s) or health effect(s) began? __________

_________________________________________________________________________

17d. What do you think caused your symptom(s) or health effect(s)?

________________________________________________________________________

________________________________________________________________________

17e. Did you miss any days of work related to the symptom(s) or health effect(s)?

☐ No

☐ Yes (How many days? _____ days)

17f. Did you see a doctor or other healthcare provider about your symptom(s) or health effect(s)?

☐ No à IF NO, SKIP TO QUESTION #18.

☐ Yes à IF YES, ANSWER #17f,i–17f,ii.

If yes,

17f,i. What diagnosis were you given for the symptom(s) or health effect(s)?

__________________________________________________________________

☐ No diagnosis given

17f,ii. Did the doctor or healthcare provider think the problem was work-related?

☐ No

☐ Yes

☐ Did not say/I don’t know

Section 4: Demographics –

Now we are going to ask you some questions about you.

18. What is your age? ___________ years

19. What is your sex? ð Male ð Female ð Other_________________

Section 5: Wrap-up

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

☐ No

☐ Yes à Please describe: ___________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

THANK YOU FOR PARTICIPATING IN OUR EVALUATION!

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