Field data collection log

Field Data Collection Log

NIOSH team member completing the form: _________________________________________________________

General Information

Data collection dates: __________________________________________________________________________

Assigned company identifier: ____________________________________________________________________

Company NAICS code: __________________________________________________________________________

Number of workers employed by this company: _____________________________________________________

Number of workers invited to participate: __________________________________________________________

Geographic location (e.g., city, state, and basin): _____________________________________________________

Location(s) where study was administered (e.g., wellsite, company yard, etc.):

_____________________________________________________________________________________________

Expected crew shift start and end time: ____________________________________________________________

Company policy on the maximum number of hours crew is allowed to work per day: _____________________________________________________________________________________________

Weather

Date

Temp. (⁰F)*

Humidity (%)

*Daily high as recorded by national weather data

Additional field notes:

(e.g., describe road condition, usual circumstances affecting work hours, etc.)

Focus groups

Group	Recorded?	Moderator	Note taker	Translator	Participants (#)	Date	Time: Start	Time: End
1
2
3
4
5

Key Informant Interviews

Interview	Recorded?	Moderator	Note taker	Date	Time: Start	Time: End
1
2
3
4
5

Actigraphy Log

Serial #	Statement of Return complete (y/n)	Check-out date	Return date	Device condition upon return	Notes

Aim 1 Participant status

Mark completed items with an “X”. If a participant does not consent to a study element, shade the box.

Participant ID

Day 1

Consent

Actigraphy

Q Baseline

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 2

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 3

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 4

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 5

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 6

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Participant ID

Day 7

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 8

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 9

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 10

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 11

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 12

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Participant ID

Day 13

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift

Day 14

Q Pre-shift

PVT Pre-shift

Q Post-shift

PVT Post-shift