0920-0260 HHE Specific Questionnaire Example

[NIOSH] Health Hazard Evaluations/Technical Assistance and Emerging Problems

Attachment D Sample HHE Specific Worker Questionnaire

OMB: 0920-0260

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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.







Shape1

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?



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


­ years and months OR ______________ start date



  1. 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


  1. 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: ___________________________________________________)


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



  1. 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


  1. 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)



  1. 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?


________________________________________________________________________


________________________________________________________________________


  1. 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)


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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?


______________________________________________________________________________


______________________________________________________________________________


______________________________________________________________________________



  1. 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: ___________________________________________________


________________________________________________________________________


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

Always

Sometimes

Never


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

Always

Sometimes

Never



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

Always

Sometimes

Never



  1. 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).


  1. 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


  1. 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


  1. 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.


  1. What is your age? ___________ years


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





Section 5: Wrap-up

  1. 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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AuthorHatcher, Sarah (CDC/NIOSH/DFSE/HETAB)
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