0920-24HM Attachment 3a - Questionnaire_Baseline

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Date: _______________ Participant ID: _______________

Assessing Fatigue and Fatigue Management in U.S. Onshore Oil and Gas Extraction:

Baseline Questionnaire

National Institute for Occupational Safety and Health

This survey features a number of statements that represent possible opinions that you may have about working in oil and gas extraction and how it may affect your sleep, fatigue, and health. The questionnaire will likely take you less than 30 minutes to complete. There are no right or wrong answers. We value your opinions to help improve workplace health and safety.

Participating in this survey is voluntary. For each question, please indicate the response option you feel best answers the question. Your answers will be kept confidential, and nothing you say in the survey will be used to identify you in any way to your employer or anyone affiliated with your employer.

This questionnaire is comprised of 6 sections related to your: A. Current Work Schedule, B. Sleep, C. Fatigue and Safety Management, D. Job Demands, E. Health, and F. Demographics. Please complete each section the best you can.

1. Current Work Schedule

This section includes questions about your current job and your current work schedule. Please answer each question the best you can.

1. In total how long have you worked in the onshore oil and gas extraction industry?

___________ years and ___________ months

2. How long have you worked in your current job in the onshore oil and gas extraction industry?

___________ years and ___________ months

3. What is your job title? (e.g., company man, toolpusher, truck driver, mud logger, roustabout, etc.)

___________________________________________

4. How would you describe your work arrangement in your current job?

   1. I am an independent contractor, independent consultant, or freelance worker

   2. I am employed by a company on a permanent basis

   3. I am employed by a company on a temporary or seasonal basis

   4. Other:

   5. Prefer not to say

5. Which of these reflect your day-to-day work schedule?

   1. Normal business hours (For example, 8 A.M. to 5 P.M.)

   2. Day shift (For example, 7 A.M. to 7 P.M.)

   3. Evening/night shift (For example, 7 P.M. to 7 A.M.)

   4. Rotating shift (Switch days and nights)

   5. Some other schedule (Please specify):

   6. Prefer not to say

6. How many hours do you typically work in a day including overtime?

__________ hours

7. What is the maximum number of hours you can work in a day?

   1. __________ hours

   2. Does not apply

   3. Prefer not to say

8. In your current job, how often do you have to work beyond this maximum number of hours?

1. Rarely/Never (once a year or less)

2. A few times a year

3. Monthly

4. Weekly

5. Several times a week

6. Prefer not to say

9. In your current job, how many days do you usually work in a row?

1. _____ days

2. It varies (please explain):

3. Prefer not to say

10. In your current job, how many days do you usually have off in a row?

    1. _____ days

    2. It varies (please explain):

    3. Prefer not to say

11. Is your commute considered to be paid time?

1. Yes

2. No

3. It varies (please explain):

4. Prefer not to say

12. What time will your trip to work usually begin?

    1. Time (HH:MM): _______ A.M. P.M.

    2. It will vary (please explain):

    3. Prefer not to say

13. On average how long is your commute?

    1. __________ hours and __________ minutes

    2. It will vary (please explain):

    3. Prefer not to say

2. Sleep

This section includes questions about your sleep, including where you sleep, your sleep behaviors, and how well you sleep. Please answer each question the best you can.

1. Is your employer providing you with housing during this work rotation?

1. Yes

2. No

3. Prefer not to say

2. [IF 1=Yes] What type of housing?

1. Man camp

2. Hotel or motel

3. Apartment or house

4. Other (please specify):

5. Prefer not to say

3. Please describe the place you sleep during your current work rotation:

	Strongly agree	Agree	Unsure	Disagree	Strongly disagree
The place I sleep is usually physically comfortable
The place I sleep is usually at a comfortable temperature
The place I sleep is usually quiet at night
The place I sleep is usually dark

3. On average, how much sleep do you get in a 24-hour period on days you are working? Think about the time you actually spend sleeping or napping, not just the amount of sleep you think you should get.

__________ hours and __________ minutes

3. Do you experience either difficulties sleeping or excessive sleepiness?

1. Yes

2. No

3. Prefer not to say

3. [IF 5=a] Is the sleep or sleepiness problem related to a work schedule that makes you work when you normally would sleep?

1. Yes

2. No

3. Prefer not to say

3. [IF 6=a] Have you had this sleep or sleepiness problem related to your work schedule for at least one month?

1. Yes

2. No

3. Prefer not to say

The following questions relate to your usual sleep habits in the past month only. Please answer all

questions.

3. During the past month, when have you usually gone to bed at night?

Usual Bed Time (HH:MM): _______ A.M. P.M.

3. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

________ Number of Minutes

3. During the past month, when have you usually gotten up in the morning?

Usual Getting Up Time (HH:MM): _______ A.M. P.M.

3. During the past month, how many hours of actual sleep did you get at night?

________ Hours of Sleep Per Night

The following questions are about issues that can disrupt sleep. Please complete each section the best you can.

12. During the past month, how often have you had trouble sleeping because you…	Not during the past month	Less than once per week	Once or twice per week	Three or more times per week	Don’t know
a. Cannot get to sleep within 30 minutes
b. Wake up unexpectedly in the middle of the night
c. Have to get up to use the bathroom
d. Cannot breathe comfortably
e. Cough or snore loudly
f. Feel too cold
g. Feel too hot
h. Have pain
i. Other reasons (please describe): ______________________

13. During the past month, how would you rate your sleep quality overall?

1. Very good

2. Fairly good

3. Fairly bad

4. Very bad

13. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?

1. Not during the past month

2. Less than once per week

3. Once or twice per week

4. Three or more times per week

5. Don’t know

13. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

1. Not during the past month

2. Less than once per week

3. Once or twice per week

4. Three or more times per week

5. Don’t know

13. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

1. No problem at all

2. Only a very slight problem

3. Somewhat of a problem

4. A very big problem

13. Do you live with a partner or roommate?

    1. No partner or roommate

    2. A partner or roommate in another room

    3. A partner or roommate in the same room, but not the same bed

    4. A partner or roommate in the same bed

18. How often has someone ever told you…	Often	A few times	Once	Never	Don’t know
a. You snore loudly
b. You take long pauses between breaths while asleep
c. Your legs twitch or jerk while you sleep
d. You had episodes of disorientation or confusion during sleep
e. You had any other restlessness while you sleep, please describe: ______________________

3. Fatigue and Safety Management

This section contains questions about practices at your current workplace, including at different levels of the organization. For each statement, please choose the response that comes closest.

Top management at this company…	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Reacts quickly to solve the problem when told about safety concerns
2. Is strict about working safely when delivery falls behind schedule
3. Uses any available information to improve existing safety rules
4. Invests a lot in safety training for workers
5. Listens carefully to our ideas about improving safety
6. Tries to continually improve safety levels in each department

My direct supervisor…	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
7. Discusses with us how to improve safety
8. Compliments employees who pay special attention to safety
9. Is strict about working safely even when we are tired or stressed
10. Frequently talks about safety issues throughout the work week
11. Refuses to ignore safety rules when work falls behind schedule
12. Uses explanations (not just compliance) to get us to act safely

13. Does your employer currently use any of the following strategies to help manage fatigue risk?

Strategy	Yes	No	I am unsure
a. Takes steps to identify what causes fatigue and takes steps to manage it
b. Policies to manage fatigue
c. Offers training and education on managing fatigue
d. Provides ways for employees to report feeling too fatigued to work safely
e. Investigates whether fatigue contributed to a workplace accident
f. Providing employees resources to help manage sleep disorders

14. Does your company have any fatigue technologies in place?

1. Yes

2. No

3. I am unsure

4. Prefer not to say

15. [IF 14=YES] What type of technology?

___________________________________________________________________

___________________________________________________________________

3. Job Demands

This section includes questions about your demands at work.

This set of questions is about how much control you have over your work. Please answer each question by checking off the one answer that best fits your job situation. Sometimes none of the answers fits exactly. Please choose the answer that comes closest.

Job control	Strongly Disagree	Disagree	Agree	Strongly Agree
1. My job requires that I learn new things
2. My job requires a lot of repetitive work
3. My job requires me to be creative
4. My job allows me to make a lot of decisions on my own
5. My job requires a high level of skill
6. On my job, I have very little freedom to decide how I do my work
7. I get to do a variety of different things on my job
8. I have a lot of say about what happens on my job
9. I have an opportunity to develop my own special abilities

The next set of questions is about the mental demands of work. Please answer each question by checking off the one answer that best fits your job situation. Sometimes none of the answers fits exactly. Please choose the answer that comes closest.

Mental Work Demands	Strongly Disagree	Disagree	Agree	Strongly Agree
10. My job requires working very fast.
11. My job requires working very hard.
12. I am not asked to do an excessive amount of work.
13. I have enough time to get the job done.
14. I am free from conflicting demands that others make.

The next set of questions is about the physical demands of work. Please answer each question by checking off the one answer that best fits your job situation. Sometimes none of the answers fits exactly. Please choose the answer that comes closest.

Physical Work Demands	Strongly Disagree	Disagree	Agree	Strongly Agree
15. My job requires lots of physical effort.
16. I am often required to move or lift very heavy loads on my job.
17. My work requires rapid and continuous physical activity.
18. I am often required to work for long periods with my body in physically awkward postures.
19. I am required to work for long periods with my head or arms in physically awkward positions.

The next set of questions is about the support you get from your supervisor and coworkers. Please answer each question by checking off the one answer that best fits your job situation. Sometimes none of the answers fits exactly. Please choose the answer that comes closest.

Social Support	Strongly Disagree	Disagree	Agree	Strongly Agree
20. My supervisor is concerned about the welfare of those under him or her
21. My supervisor pays attention to what I am saying
22. My supervisor is helpful in getting the job done
23. My supervisor is successful in getting people to work together
24. People I work with are competent in doing their jobs
25. People I work with take a personal interest in me
26. People I work with are friendly
27. People I work with are helpful in getting the job done

3. Health

This section includes questions about your health. Please answer each question the best you can.

1. Would you say your health in general is excellent, very good, good, fair, or poor?

   1. Excellent

   2. Very Good

   3. Good

   4. Fair

   5. Poor

   6. Don’t know

   7. Prefer not to say

2. Do you regularly take any medication that may result in fatigue?

1. Yes

2. No

3. Prefer not to say

3. On days that you work, on average how much of the following do you consume per day?

	Amount	I do not use	Prefer not to say
Caffeinated Beverages
Cups of coffee or tea (8 oz)
Cans of soda (12 oz)
Cans of energy drinks (8 oz.; e.g., Monster, Redbull)
Bottles of 5-hour Energy (2 oz)
Nicotine
Cigarettes
Cigars, cigarillos, or little filtered cigars
Electronic cigarettes (number of puffs per day)
Cans/packages of smokeless tobacco

4. Do you use anything else to help you stay alert at work?

_______________________________________________________________________________

5. How tall are you without shoes?

   1. _____ Feet

   2. _____ Inches

   3. Don’t know

   4. Prefer not to say

5. How much do you weigh?

   1. _____ lbs

   2. Don’t know

   3. Prefer not to say

3. Demographics

This section includes questions about your demographics. Please answer each question the best you can.

1. What is your age?

   1. ______ years

   2. Prefer not to say

2. What is your race and/or ethnicity? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Middle Eastern or North African

• Native Hawaiian or Pacific Islander

• White

3. What sex were you assigned at birth, on your original birth certificate?

   1. Male

   2. Female

   3. I don’t know

   4. Prefer not to say

4. How do you describe your current gender? Select all that apply.

   1. Male

   2. Female

   3. Transgender

   4. None of these

   5. Prefer not to say

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

   1. 8^th grade or less

   2. 9^th-12^th grade (no diploma)

   3. GED or equivalent

   4. High school graduate (diploma)

   5. Some college (no degree)

   6. Associate degree

   7. Bachelor’s degree or higher

   8. Don’t know

   9. Prefer not to say

6. Are you now married, living with a partner, or neither?

   1. Married

   2. Living with a partner

   3. Neither

   4. Don’t know

   5. Prefer not to say

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-XXXX).