Demographic Survey (Amended)

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 sex? (check one)

 Male

 Female

3. Is your vision normal or corrected to normal?

 Yes

 No (please inform researcher)

4. Is your hearing normal or corrected to normal? 

 Yes  

 No (please inform researcher) 

5. Which racial/ethnic category best describes you? (Select all that apply.)

6. Job experience

   1. Current manufacturing, warehouse, or stockroom employee: Yes | No

   2. Years of working in the manufacturing industry, warehousing industry, or in a stockroom: _______ 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333. ATTN: PRA (0920-1441)