Appendix C: Low Back Assessment

Appendix C

LOW BACK ASSESSMENT TOOL

Form Approved

OMB No. ________

Exp. Date: ________

LOW BACK EXPOSURE ASSESSMENT TOOL

1. Job Title _________________________

2. How long have you been in your current job?_________years ________months

(If less than 5 years): What other jobs have you had in the past 5 years?_________________________________________

3. How many years have you been with your current company?_______

4. Typical days worked/week (circle): 1 2 3 4 5 6 7

Less than 8 hours
8-10 hours
10-12
12+

Shift Length (please check):

5. Gender (please check):

M
F

6: Age: ______ years

7. Height: ______ft _______ inches

8. Weight (lbs.): ____________

9. Smoking status (circle): Never smoked Former smoker Current smoker

IF CURRENT OR FORMER SMOKER:

	# Years	Packs/day
Current Smoker?
Former Smoker?

Public reporting burden of this collection of information is estimated to average 15 minutes per response. 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX).

10. Belts worn/weight:

	No	Yes	If YES, Estimated weight of belt?
Wear Mining belt?
Wear Tool belt?

11. Seam Height Restrictions (please check):

Surface mine (no restrictions)
Underground >72”
Underground 61-72”
Underground 49-60”
Underground < 48”

12. When performing your normal job duties, how often do you normally use the following postures? (please check one box for each posture listed):

	Never	Rarely	Occasionally	Frequently	Almost Always
Standing
Sitting
Stooping
Kneeling
Squatting
Lying down
Twisted Trunk

13. During your 1^st hour of work, do you usually have to stoop over or sit for > 30 minutes (circle)?

Y N

14. In performing your regular job, how many days per week do you have to lift items weighing 20 pounds or more (circle)?

0 1 2 3 4 5 6 7

In your normal job, how many periods of lifting do you do per day (on average)?__________

For each period of lifting, about how many items would you typically lift? ___

15. Do you ever lift loads > 50 pounds (circle)? Y N

(If Y): > 75 pounds? Y N

(If Y): > 100 pounds? Y N

18. When you do lifting tasks, where are the objects typically located at the start of the lift (circle)?

Below knees Between knees and shoulders Above shoulders

19. Do you ever have to lower items to the floor (circle)? Y N

21. Approximately how many hours do you drive or ride in a vehicle in a typical workday (circle)?

< 1 hour 1-4 hours >4 hours

22. Would you describe the road surfaces that you drive on as (circle):

Smooth (paved) Bumpy (gravel) Jarring (large holes or ruts)

23. How well does your vehicle or seat absorb the shocks (circle)?

Not well Reasonably well Very well

24. Does your seat provide good low back support (circle)? Y N

25. How would you rate your overall satisfaction with your present job (circle)?

Not satisfied Somewhat satisfied Very satisfied

26. How would you rate your job in terms of stress level (circle)?

Not very stressful Somewhat stressful Very stressful

27. At the end of the work day, how would you rate your energy level (circle)?

Not tired Somewhat tired Very tired

28. How would you rate the time pressure on this job (circle)?

Little time pressure Some time pressure Frequent time pressure

29. During the past 12 months, have you experienced any low back pain (circle)? Y N

If Y, how many episodes of low back pain have you had in the past 12 months (circle)?

1 2 3 4+

30. How many total days have you experienced back pain in the past year (circle)?

< 1 week 1-4 weeks 1-3 months >4 months

31. To what degree did your back pain cause you to restrict your normal daily activities?

No restrictions Moderate restrictions Severe restrictions

32. Did the back pain cause you to miss any work (circle)? Y N

(If Y): How many days of work did you miss? __________________

33. Was your pain confined to your lower back or did you have radiating pain (for example, into buttocks or legs)?

Lower Back Only Radiating Pain

34. Has a medical professional given you a specific reason (or diagnosis) as to what is causing your back pain (circle)? Y N

If Y: Can you tell us the diagnosis? ___________________________________________

Thank you for your time and responses.