Form 0920-1154 Nail Salon Exposure Study Questionnaire (24FD)

Form Approved

OMB No. 0920-1154

Exp Date 3/31/26

Nail Salon Exposure Study Questionnaire

1. Please enter your NIOSH ID number.

   1. ___

Exposure Assessment

In this section, we will ask questions about the salon you work in and some of the things you do while working. These questions will help us understand your exposure to chemicals better.

2. How many hours a week do you work at the salon?

   1. ___

3. What is your current role at the salon? Select all that apply.

   1. Apprentice/trainee

   2. Nail technician/manicurist

   3. Manager

   4. Owner

   5. Other, please explain _________

4. How many years have you worked in a nail salon?

   1. ___

5. At what age did you begin working in a nail salon?

   1. ___ years old

6. How many people work in the salon with you on a typical day?

   1. ___ people

7. Do you use gloves at work?

   1. Always

   2. Sometimes

   3. Never

8. Do you use a face covering or mask at work?

   1. Always

   2. Sometimes

   3. Never [skip to question #10]

Public reporting burden of this collection of information is estimated to average 20 mins 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 (0920-1154).

9. What kind of face covering or mask do you wear at work? Select all that apply.

   1. Cloth face mask

   2. Disposable surgical mask

   3. KN95, KN94, etc.

   4. N95 disposable

   5. Other, please explain _________

   6. Don’t know

10. Does your salon have Safety Data Sheets (SDS) for the products you use?

    1. Yes

    2. No

    3. Not sure

11. Have you received any training at work about working safely with chemicals?

    1. Yes

    2. No

12. Do you use chemicals to clean your tools?

    1. Yes

    2. No

13. Are there any things done at the salon to lower the amount of chemicals you might breathe or get on your skin? Select all that apply.

    1. Opening doors/windows

    2. Using fans

    3. Using ventilated tables

    4. Local exhaust ventilation to the outside

    5. Keeping containers closed when not being used

    6. Keeping the trash covered

    7. Labeling chemicals correctly

    8. Other, please explain _________

    9. Don’t know

    10. None

14. How often over the last week did you perform the following services?

    1. Traditional polish manicure or pedicure

       1. ____ times

    2. Gel polish manicure or pedicure

       1. ____ times

3. Acrylic full set (sculpt/tips) or fill

   1. ____ times

4. Acrylic extension removal

   1. ____ times

5. Gel full set (traditional or hard gel extensions) or fill

   1. ____ times

6. Gel extension removal

   1. ____ times

7. Tube gel full set

   1. ____ times

8. Tube gel removal

   1. ____ times

9. Dip/SNS powder full set

   1. ____ times

10. Dip/SNS powder removal

    1. ____ times

15. Do you use an electric file or drill in your work?

    1. Yes

    2. No

16. Do you now smoke cigarettes, cigars, e-cigarettes, and/or vape pens?

    1. Every day

    2. Some days

    3. Not at all

Demographics

We will now ask some questions to learn more about you. If you would prefer not to answer a question, you may leave it blank.

17. How old are you?

    1. ____ years old

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

    1. American Indian or Alaska Native

    2. Asian

    3. Black or African American

    4. Hispanic or Latino

    5. Middle Eastern or North African

    6. Native Hawaiian or Pacific Islander

    7. White

19. Please provide additional detail. [only show if 18b is selected]

    1. Chinese

    2. Asian Indian

    3. Filipino

    4. Vietnamese

    5. Korean

    6. Japanese

    7. Other ______ (Enter, for example, Pakistani, Hmong, Afghan, etc.)

20. Were you born in the U.S.?

    1. Yes

    2. No

    3. Prefer not to answer

21. Do you speak a language other than English at home?

    1. Yes

    2. No [skip to question 23]

22. How well do you speak English?

    1. Very well

    2. Well

    3. Not well

    4. Not at all

23. What is the highest grade or year of school you completed?

    1. Never attended school or only attended kindergarten

    2. Grades 1 through 8 (Elementary)

    3. Grades 9 through 11 (Some high school)

    4. Grade 12 or GED (High school graduate)

    5. College for 1 year to 3 years (Some college or technical school)

    6. College for 4 years or more (College graduate or advanced graduate education)

24. What is your current marital status?

    1. Married

    2. Widowed

    3. Divorced

    4. Separated

    5. Never married

    6. Living with partner

    7. Prefer not to answer

25. What was your sex at birth?

    1. Male [skip to question 40]

    2. Female

Reproductive history

We will now ask you some questions about past pregnancies. If you would prefer not to answer a question, you may leave it blank.

26. Are you currently pregnant or trying to become pregnant?

    1. Yes

    2. No

    3. Prefer not to answer

27. How many times have you been pregnant in your life? (Please include current pregnancy, live births, miscarriages, stillbirths, ectopic or tubal pregnancies and abortions)

    1. ____ times [if 0, skip to question 40]

28. How old were you when you got pregnant for the first time?

    1. ____ years old

29. How many of your pregnancies resulted in a live birth?

    1. ____ [if 0, skip to question 31 AND skip questions 35-39]

30. How old were you at the time of your first live birth?

    1. ____ years old

Workplace reproductive health

In this section, we are going to ask you some questions about whether you changed anything about your work in a salon while pregnant or breastfeeding. When answering these questions, please think about whether you did things differently at work because you were pregnant or breastfeeding.

31. Were you working in a nail salon during any of your pregnancies?

    1. Yes

    2. No [skip to question 36]

32. How many times have you been pregnant while working in a nail salon?

    1. ____ times

33. During any of these pregnancies, did you work in a nail salon during the first three months of pregnancy?

    1. Yes

    2. No

34. During any of these pregnancies, did you change anything about your work in the nail salon?

    1. Took extended time off from work (paid or unpaid)

       1. Yes

       2. No

    2. Worked with nail salon products or chemicals less

       1. Yes

       2. No

    3. Worked more hours

       1. Yes

       2. No

    4. Worked fewer hours

       1. Yes

       2. No

    5. Worked the same number of hours, but changed your typical schedule

       1. Yes

       2. No

    6. Began wearing gloves, or wore gloves more often

       1. Yes

       2. No

    7. Changed the type of gloves that you wore

       1. Yes

       2. No

    8. Began wearing a face covering or mask, or wore a face covering or mask more often

       1. Yes

       2. No

    9. Changed the type of face covering or mask that you wore

       1. Yes

       2. No

    10. Other: Please tell us: _______

35. During your time working in a nail salon, did you ever breastfeed or pump breast milk to feed your baby, even for a short period of time (including times inside or outside of the nail salon)?

    1. Yes

    2. No [skip to question 40]

36. Are you currently breastfeeding or feeding pumped milk to your baby?

    1. Yes

    2. No

37. During any times you were breastfeeding or feeding pumped milk to your baby, did you take any maternity leave or extended time off from your nail salon work (paid or unpaid)?

    1. Yes, I took off work the entire time I was breastfeeding or pumping milk [skip to question 40]

    2. Yes, I took off work some of the time I was breastfeeding or pumping milk

    3. No, I did not take off work during the time I was breastfeeding or pumping milk

38. During any times you were breastfeeding or feeding pumped milk to your baby, did you change anything about your work in the nail salon while you were not taking time off?

    1. Worked with nail salon products or chemicals less

       1. Yes

       2. No

    2. Worked more hours

       1. Yes

       2. No

    3. Worked fewer hours

       1. Yes

       2. No

    4. Worked the same number of hours, but changed your typical schedule

       1. Yes

       2. No

    5. Began wearing gloves, or wore gloves more often

       1. Yes

       2. No

    6. Changed the type of gloves that you wore

       1. Yes

       2. No

    7. Began wearing a face covering or mask, or wore a face covering or mask more often

       1. Yes

       2. No

    8. Changed the type of face covering or mask that you wore

       1. Yes

       2. No

    9. Other: Please tell us: _______

39. If you have children, how often did you bring them to work with you in the nail salon while they were infants or young children (age 5 or younger)?

    1. Very Often

    2. Somewhat Often

    3. Sometimes

    4. Almost Never

    5. Never

    6. Not applicable, I do not have children, or my children were not young when I worked in a nail salon

40. How strongly do you agree with the following statements: I think my nail salon work or exposures could/did affect…

    1. My ability to become pregnant or give birth

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable

    2. The health of my children at birth (for example: low birthweight, preterm delivery, birth defects, stillbirth)

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable

    3. The health of my children later in life

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable

    4. My own health during pregnancy

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable

    5. My menstrual cycle, periods, or menopause

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable

    6. My ability to breastfeed or pump milk to feed my children

       1. Strongly Agree

       2. Agree

       3. Undecided

       4. Disagree

       5. Strongly Disagree

       6. Not applicable