Form no number no number Customer Survey

Attachment C-2: Survey Instrument

OMB Control No. __________

Expiration Date __________

Workplace Health Hazard Survey

This survey is being conducted by the Centers for Disease Control and Prevention (CDC), an agency in the U.S. Department of Health and Human Services. Your answers will help CDC improve how they keep people informed about services for reducing exposure to workplace health hazards.

1. What industry do you work in? (Please check one)

__ Food and Beverage Manufacturing (Go to 1a)

__ Services to Buildings and Dwellings (Go to 1b)

__ Other (please specify:_______________________) (Go to 2)

1a. What type of food and beverage manufacturing? (Please check one.)

__ Meat products

__ Dairy products

__ Canned, frozen, and preserved fruits, vegetables and food specialties

__ Grain mill products

__ Bakery products

__ Sugar and confectionary products

__ Fats and oils

__ Beverages

__ Other (please specify:_______________________)

1b. What type of services to buildings and dwellings? (Please check one.)

__ Pest control services

__ Building cleaning and maintenance services

__ Carpet and upholstery cleaning services

__ Lawn and garden services

__ Other (please specify:_______________________)

Public reporting burden of this collection of information is estimated to average 15 minutes 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 the is collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333.

2. How long have you worked in this industry? (Please check one.)

__ Less than one year

__ 1-4 years

__ 5-9 years

__ 10-14 years

__ 15-or more years

3. Overall, how many total employees work for your entire company? (Please check one.)

__ Less than 50 employees

__ 50-99 employees

__ 100-249 employees

__ More than 250 employees

4. In your current workplace, which of the following describe you? (Please check all that apply.)

__ Owner/Chief executive

__ Salaried employee

__ Unionized wage-earner

__ Non-unionized wage-earner

__ Supervisor

__ Manager

__ Union representative

__ Health and Safety Committee member

__ Industrial hygienist/Safety professional

__ Human resources professional

__ Other (please specify:_______________________)

5. Are you…? (Please check one.)

__ Female

__ Male

6. Are you…? (Please check all that apply.)

__ American Indian or Alaska Native

__ Asian

__ Black or African American

__ Native Hawaiian or Other Pacific Islander

__ White

__ Other

7. Are you Hispanic/Latino? (Please check one.)

__ Yes

__ No

8. In your current workplace, how concerned are you about each of the following health hazards? (To appear in random order)

	Not at all concerned	A little concerned	Moderately concerned	Very concerned
a. Chemical hazards (e.g., flavorings, solvents, pesticides, lead, asbestos)
b. Physical hazards (e.g., noise, radiation, heat, cold)
c. Biological hazards (e.g., mold, infectious agents, blood, human waste products)
d. Ergonomic hazards (e.g., repetitive motion, heavy lifting)
e. Other: (please specify: _______________________________)

9. Do you believe that workplace health hazards in your current workplace are causing any of the following types of symptoms, diseases, disorders, or injuries to workers? (To appear in random order)

	Yes	No	Not sure/ Don’t know
a. Lung problems (e.g., shortness of breath, asthma, chronic obstructive pulmonary disease - COPD)
b. Brain or nervous system problems (e.g., dizziness, numbness, headache, twitching, loss of nerve function)
c. Skin conditions or diseases (e.g., rash, eczema, contact dermatitis, oil acne, friction blisters)
d. Muscle and bone injuries that occur from a one-time event (e.g., muscle strain, broken bone)
e. Muscle and bone conditions that develop over time (e.g., lower back pain, carpal tunnel syndrome)
f. Reproductive system problems (e.g., infertility, menstrual cycle disruption)
g. Heart problems (e.g., chest pain, irregular heart beat, heart palpitations, high blood pressure)
h. Immune system problems (e.g., allergies, lupus, inflammation)
i. Mental health and stress-related problems (e.g., depression, anxiety, chronic fatigue, insomnia, irritability, post-traumatic stress disorder)
j. Cancer
k. Hearing loss
l. Other: (please specify:___________________)

10. Have you ever heard of the Health Hazard Evaluation (HHE) Program?

__ Yes [continue to Q11]

__ No [go to HHE definition on page 5]

__ Not sure/don’t know [go to HHE definition on page 5]

If yes:

11. Who runs the HHE Program? (To appear in random order)

__ National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC)

__ Occupational Safety and Health Administration (OSHA), part of the U.S. Department of Labor (DOL)

__ National Institutes of Health (NIH)

__ U.S. Food and Drug Administration (FDA)

__ Not sure/don’t know

12. Have you ever…? (Check all that apply.) (To appear in random order)

__ Looked for information about the HHE Program?

__ Visited the HHE Program website?

__ Submitted a request for an HHE?

__ Participated in an HHE visit to your workplace?

__ Received or read materials from the HHE Program?

__ Seen HHE materials displayed or made available in your workplace?

__ Seen or read information about findings from an HHE?

Text to appear for all respondents

A Health Hazard Evaluation (HHE) is a study of hazards in a workplace. It can be requested by employees, employers, or union representatives. It is done to learn whether workers are exposed to hazardous materials or harmful conditions and provides information on how workers can be protected. An HHE is conducted by the National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Protection (CDC), an agency of the federal government. Personal information from records, questionnaires, interviews with NIOSH investigators, and individual medical results are protected. If requested, NIOSH will not reveal to the employer the names of the persons who made the request.

[Continue to Q13]

For all to answer:

13.How important is it that a program like the HHE Program…? (To appear in random order)

	Not at all	A little	Moderately	Very	Not sure/ Don’t know
a. Provides an objective and scientific evaluation of health hazards
b. Is conducted by an agency of the federal government
c. Not reveal to employers the names of those requesting an HHE without their consent
d. Provides protection under the law to employers such as protecting trade secrets
e. Provides protection under the law to employees such as protecting whistleblowers
f. Helps employees, employers, and unions recognize hazards in the workplace
g. Works to improve worker health and safety
h. Cannot punish or regulate employers
i. Helps employers reduce hazards in the workplace
j. Provides materials in languages other than English (please specify languages: _______________________)

14. Please indicate whether each of the following factors would make you more or less likely to request an HHE. (To appear in random order)

	Much less likely	Somewhat less likely	Neither less nor more likely	Somewhat more likely	Much more likely
a. Federal government employees might visit the workplace
b. There would be no charge to the workplace for conducting the HHE
c. Production processes or employee work practices might be observed and photographed
d. Air and surface samples may be collected
e. Employees might be interviewed
f. Medical tests or physical examinations of employees might be performed
g. Injury and illness records could be reviewed
h. It could be expensive to correct or remove the hazard
i. Employees will not be punished for discussing or revealing the hazard
j. Employee illness due to a workplace hazard could be determined
k. Suggestions or options for correcting safety and health issues could be received
l. Worker compensation costs or claims could be reduced
m. Health hazards in the workplace may be reduced
n. A healthier workplace could be created
o. Worker health and productivity might be improved
p. A report with the name of a company evaluated in an HHE could be published

15. Which of the following would be useful ways for you, your coworkers, or your employees to learn more about the HHE Program? (Check all that apply.) (To appear in random order)

___ a. One-page fact sheets or flyers

___ b. Brochures or pamphlets

___ c. Posters or other items to display in the workplace

___ d. On-site presentations by HHE staff

___ e. Toll-free hotline

___ f. TV or radio advertisements

___ g. Newspaper articles

___ h. Web pages or Web sites

___ i. Teleconferences or conference calls

___ j. Presentations or displays at professional associations or meetings

___ k. Magazine or journal articles

___ l. Video, DVD, or on-line video clips

___ m. Other (please specify): _________________________

16. How likely are you to use workplace health and safety information in each of the following formats? (To appear in random order)

	Not at all likely	A little likely	Moderately likely	Very likely
a. Printed or hard copy materials
b. Web sites, electronic files, or PDFs

17. How often do you use the following resources for workplace health and safety information? (To appear in random order)

	Never	Rarely	Occasionally	Often
a. Business or trade organizations/ periodicals (please specify: __________________)
b. Occupational safety and health organizations/ associations (please specify: __________________)
c. Medical or occupational safety and health professionals (please specify: __________________)
d. Unions (please specify: __________________)
e. Coworkers or colleagues at work
f. Supervisors or managers at work
g. Federal government agencies or offices (please specify: __________________)
h. State or local government agencies or offices (please specify: ___________________)
i. Mass media sources (e.g., newspapers, magazines, TV or radio)
j. Internet sources or Web sites (please specify: ___________________)
k. Meetings, workshops or conferences (please specify: ___________________)
l. Other (please specify: ___________________)

18. What do you consider to be the most trusted source of information on workplace health and safety? (Please check one.) (To appear in random order)

___ a. Business or trade organizations/periodicals

___ b. Occupational safety and health organizations/associations

___ c. Medical or occupational safety and health professionals

___ d. Unions

___ e. Coworkers or colleagues at work

___ f. Supervisors or managers at work

___ g. Federal government agencies or offices

___ h. State or local government agencies or offices

___ i. Mass media sources (newspapers, magazines, TV or radio)

___ j. Internet sources or Web sites

___ k. Meetings, workshops or conferences

___ l. Other (please specify: ___________________)

Thank you for completing this survey.

To learn more about the

National Institute for Occupational Safety and Health (NIOSH)

Health Hazard Evaluation (HHE) Program

please visit

http://www.cdc.gov/niosh/hhe/default.html

or call

1-800-CDC-INFO (1-800-232-4636).

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