0920-25CW Demographic Survey

Form Approved

OMB No. 0920-1441

Exp. Date 09/30/2027

Attachment C: Demographic Survey

Demographic Survey

1. What is your age? ________________________

2. What is your dominant hand?

Left | Right

3. Are you: (Mark all that apply.)

 Male

 Female

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

5. Job experience

   1. Currently employed in manufacturing/warehousing or similar industry? YES | NO

2. Years of experience: _______ years

Public reporting burden of this collection of information is estimated to average 1 minute 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/ Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333. ATTN: PRA (0920-1441).