Attachment C Interview Example

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

HHE Number: 

Interviewer:				

Date: 

Name: __________________________________

Hello, my name is _______.  I’m part of a team from the Centers for Disease Control and Prevention that is investigating (insert concern here) among employees at the (facility name). Brief description of concern and why it is a concern. We’d like to ask you some questions regarding your health, work, and activities that should help us learn more about worker exposures. It should take 15–20 minutes. Your individual responses will be used only for the purposes of this evaluation and will be kept strictly confidential. We will group your responses into summary results so your individual responses cannot be identified. Participation in this interview is voluntary; you may decline to answer any of the questions at any time.

Work history
I’d like to start by asking you some questions about your work.

    1. What is your current job title? 									
	
    2. What is your basic job description?										
    3. During a typical week, which building(s) or area(s) do you work in?					

    4. What is your primary work shift? (circle one) 	
First		Second			Third			
Other (please explain, ask shift start and end times)   				

    5. How many hours, on average, do you work a week at (facility name)? __________ hours per week

    6. How long have you worked at (facility name)? _________ years	________ months

Work practices
The next questions deal with your usual work practices.
    7. During your work day, how many hours, on average, do you spend 
    a. Walking to and from your car or van pool?			_____ hours  ____ minutes
    b. Outdoors during gym or physical training (PT) time? 	_____ hours  ____ minutes
    c. Walking from building to building?				_____ hours  ____ minutes
    d. Working outdoors?						_____ hours  ____ minutes
			
    8. Do you eat outside while at work?	Yes	No	
If yes, during your work day, how much time do you spend eating outside, on average?
_____ hours ___ minutes

    9. What types of activities do you do when working outdoors? Check all that apply
	 Operate machinery If checked, please continue to question #10. Otherwise, go to question #11
 Assemble or disassemble pallets
	 Load or unload materials onto trucks 
	 Providing security at the gate
	 Patrol 
	 Other, please specify 									

    10. Only if “Operate machinery” was checked for question #9. Otherwise, go to question #11.
    a. What type of machinery do you operate outdoors? Check all that apply
 Forklift
 Other, please specify								
    b. Does operating this machinery kick up dust? 	Yes	No
    c. Do you operate machinery with a closed or open cabin?	
 Open	
 Closed	
 Both	
 Not applicable
    d. Do you use any respiratory protection? 		Yes	No
If yes, what type? 								

    11. Does your job involve being near activities that disrupt soil?	Yes	No
	If yes,
    a. How often you are near soil disruption activities at this facility?  
Constantly		Sometimes	Rarely
    b. Where is/were the soil disruption activities? 						
    c. What types of soil disruption activities? 						
    d. What types of equipment were being used? 							
    e. Do you use any respiratory protection when you work near soil disrupting activities? 
Yes	No
		If yes, what type(s)? 								
	
    12. What building do you primarily work in? 							
    a. When working indoors in this building, how often are the doors or bays open to the outdoors? 
 Constantly
 Sometimes 
 Never
 Not applicable (please explain)							
If constantly or sometimes, were the doors or bays only open because it was necessary for work activities? 	Yes	No	Not sure	

    13.  Do you work with materials that are dusty from being outside? 	Yes	No	Not sure

    14. Before this interview started, had you ever heard of (hazard or disease)?	Yes	No

    15. Since you started working at (facility name), have you ever received training on (hazard or disease) might relate to your work here?		Yes	No
	If yes, Please describe the type of training and who provided it: 					

    16. Do you currently have access to an N95 respirator or other respirator?	
Yes	No

    17. Have you ever used an N95 respirator or other respirator when exposed to dust during your work here? 	Yes	No
	If yes,
    a. Was respirator use required or voluntary? (circle one)
Required	Voluntary 	Other (please explain)					
    b. Please list the instances when you have used one: 						
    c. What type of respirator have you worn? Check all that apply.
		 NIOSH-approved filtering facepiece respirator (N95)	
		 Other, please describe: 								
    d. In the last year, 
    i. Did you have medical evaluation to be cleared for using a respirator? 
Yes 	No	Not sure
    ii. Did you have respirator fit testing? 		Yes 	No	Not sure
    iii. Did you have training on respirators? 		Yes 	No	Not sure

Other Exposures
    18. Outside of work, how many hours, on average, do you spend outdoors each day?
 _______ hours _______ minutes

    19. Regarding your activities, which of the following do you do regularly? 
    a. Gardening				Yes	No
    b. Hiking/walking/running		Yes	No
    c. Golfing				Yes	No
    d. Biking				Yes	No
    e. Other outdoor activity		Yes	No	
If yes, specify: __________________________

Residence history (skip if no geographical impact on hazard or disease)
I’d like to ask you some questions about your place of residence.
    20. What town or city do you currently live in?  ________________________	

    21. Please list all of the places you have lived (city, state) in California, Nevada, Arizona, New Mexico, Utah, Texas, and Mexico and the length of time lived there. Work backwards in time.
City
State
Length of time (years, months)












Medical History
I’d like to ask you some questions about your health. 
    22. Do you have any of the following medical conditions? (check all that apply)
 Cancer requiring chemotherapy or radiation therapy		
 Any disease that suppresses the immune system, including HIV or AIDS
 Lung disease, including asthma, COPD, emphysema, or other lung disease
 Diabetes mellitus
 Heart disease
 Solid organ transplant 
 Bone marrow transplant 
 Liver disease 
 Kidney disease 

    23. Are you taking any medications that suppress your immune system (e.g., prednisone, cyclosporine, methotrexate)?			Yes	No

    24. Do you currently smoke tobacco?  	Yes	No

Illness history
    25. Have you ever been diagnosed with (disease of concern)? 	Yes	No
If no, go to next question (#26). 
If yes, ask the following
a. When did your symptoms start? mm 		/dd 		 /yyyy 			 
	i. Was this before or after you started working at DLA San Joaquin? 
Before		After		Not sure

	b. How long did you live in the (area) before your diagnosis? ________ years

c. Were you told that you had disseminated disease (spread out in the body)? 
Yes	No	Not sure

d. Did you have 
i. skin lesions			Yes 	No	Not sure
ii. bone or joint infection	Yes 	No	Not sure
iii. meningitis 			Yes	No	Not sure
(swelling/inflammation of tissue surrounding the brain and spinal cord)

    e. Were you hospitalized because of (disease of concern)?	Yes	No 

    f.  How many days were you absent from work as a result of (disease of concern)? ____________ days

    g.  Did you report this illness to your employer? 	Yes	No

    h. Can we obtain your permission to obtain your medical records?	Yes	No
If yes, give consent form and ask them to complete. Attach to this form.

Demographics
    26. What is your date of birth? mm______/dd______/yyyy______			

    27. What is your sex? 	Female		Male		Other
	If female: are you currently pregnant? Yes	No	Not sure

    28. How would you describe your race? (circle as appropriate)
American Indian or Alaskan Native		
Asian
If Asian, are you Filipino?	Yes	No
Black or African American	
Native Hawaiian or other Pacific Islander
White
Other, specify: ____________________

    29. Are you Hispanic/Latino? 	Yes	No

    30. Do you have any other health or safety concerns related to your work here? 

_____________________________________________________________________________________
_____________________________________________________________________________________

Thank you for participating in this interview. Depending on what we find out when we put these interviews together, we may need to follow up about a few details. Is there a phone number and e-mail address we may have in case we need to reach you?   
Phone number: (        ) ______-__________
E-mail address: _________________________


Privacy Act Statement
The National Institute for Occupational Safety and Health (NIOSH) Health Hazard Evaluation (HHE) Program collects this information under Section 20 of the Occupational Safety and Health Act (29 U.S.C. § 669). Collection of the last four digits of your Social Security Number is authorized pursuant to Executive Order 9397, as amended. NIOSH will use the information you provide to conduct Health Hazard Evaluations, maintain accurate participant records, perform follow-up activities when necessary, and distinguish among individuals with similar names to ensure accurate record matching and management. Providing this information is voluntary; however, failure to provide requested identifying information, including the last four digits of your Social Security Number, may limit NIOSH's ability to accurately maintain records or conduct follow-up activities.

The Privacy Act of 1974 (5 U.S.C. § 552a) governs the collection and use of this information. Records are maintained in CDC/NIOSH System of Records Notice (SORN) 09-20-0147, Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records. Information may be disclosed outside CDC only as permitted by the Privacy Act, in accordance with the routine uses published for this system of records, and as otherwise authorized by law. Records will be maintained and protected in accordance with applicable federal privacy and security requirements.