Instructions: Please answer the following demographic questions.
Where is the mine(s) you work at located (state)? _________________________________
What is the primary commodity produced at your mine(s)? _________________________
What type of operation is it? (Pick all that apply):
☐ Underground mine
☐ Surface mine
☐ Preparation / Processing Plant
☐ Office
☐ Other __________________________________________
What is your current job title: _____________________________
Number of years in your current job title: __________ years
Number of years at your current mine: __________ years
Number of years of total mining experience: __________ years
Age: __________ years
Education (select one):
○ Less than high school
○ High school/GED
○ Some college
○ Bachelor’s degree or higher
○ Prefer not to answer
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
Are you (select all that apply):
☐ Female
☐ Male
☐ Transgender, non-binary, or another gender
☐ Prefer not to answer
Which of the following best represents how you think of yourself?
☐ Bisexual
☐ Gay or lesbian
☐ Heterosexual / straight
☐ I use a different term [please self-describe]: ____________________________
☐ I don’t know
☐ Prefer not to answer
What was your entire household income last year before taxes?
☐ <$20,000
☐ $20,000 to $34,999
☐ $35,000 to $49,999
☐ $50,000 to $74,999
☐ $75,000 to $99,999
☐ $100,000 to $149,999
☐ $150,000 to $199,999
☐ $200,000 or more
☐ Prefer not to answer
Are you the head of your household?
☐ Yes
☐ No
☐ Prefer not to answer
What is your current marital status?
☐ Divorced
☐ Married or living with partner
☐ Never married
☐ Separated
☐ Widowed
☐ Prefer not to answer
How many dependents currently live in your household? Please enter the total number in each age category.
Total number of household members aged 0 to 5: __________
Total number of household members aged 6 to 12: __________
Total number of household members aged 13 to 17: __________
Total number of household members aged 18 or older: __________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dugdale, Zoe (CDC/NIOSH/SMRD/MHB) |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |