HHE Evaluation
Health Hazard Evaluations/Technical Assistance and Emerging Problems
Attachment F- updated
Health Hazard Evaluation Specific Questionnaire (Example)
OMB: 0920-0260
ID# 001
Form Approved OMB No. 0920-0260
Expires 1/30/2012
U. S. Department of Health and Human Services
U. S. Public Health Service
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
Health Hazard Evaluation 2010-0144
GE Aviation
Cincinnati, Ohio
This questionnaire is part of a National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation (HHE) of workplace health issues at GE Aviation in Cincinnati, Ohio. This questionnaire includes questions concerning health symptoms that you may have experienced or be experiencing, and some questions about your current job and work history. Participation in this HHE and completion of this questionnaire are voluntary. There is no penalty for choosing not to participate. However, full participation will better enable NIOSH to assess current health issues among employees at your workplace.
Please answer all questions to the best of your ability. If you don’t understand any of the following questions, please ask for assistance. All personal information from this questionnaire will be kept confidential according to federal law. Group summary results of this evaluation (without any personal identifying information) will be provided to employees, union representatives, and management in a final report after the evaluation is complete.
Name:____________________________________________________________________
Public reporting burden for this collection of information is estimated to average 30 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 this collection of information including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: P.A. (0920-0260). Do not send the completed form to this address.
Today’s date: ______/______/2011
month / day
What is your age?
_______ years
What is your sex?
Female
Male
In total, how long have you worked at GE Aviation?
_______ years
If less than 1 year, please enter the number of months worked: ____________months
In which building do you currently work? If you work in both building 700 and 800, mark the one in which you work the most hours.
700
800
Other (specify: _____________________________)
What is your current work area? (Check only one box.)
Seals
Large Parts
Shafts
IPE/Nozzles
Casing
Turbine Rear Frame
Turbine Mid Frame
Frames
Fins
Punch Press
Administrative Offices
Other (specify: _____________________________)
What is your current job title? (Check only one box.)
Production Mechanic
Production Cell Machine Operator
Tool Maker
Tester
Maintenance
Administrative or Clerical
Other (specify: _____________________________)
How long have you worked in your current job title at GE Aviation?
_______ years
If less than 1 year, please enter the number of months worked: ___________months
How many hours per week do you usually work at GE Aviation?
_____ hours per week
Do you usually work with coolant in your current job title at GE Aviation?
No Yes
If no, please answer the following question and then skip to Question #14
Have
you ever worked with coolant at GE Aviation?
No
Yes
What kind of inserts do you use at work?
Carbide inserts only
Ceramic inserts only
Both carbide and ceramic inserts
I don’t work with inserts
Do the machines you work with have a mist collector?
Yes, all have a mist collector
Yes, some have a mist collector
No, none have mist collectors
I
Do
you feel that the mist collector is functioning properly to control
the coolant mist? Yes
No If no, please list machine number(s)
______________
How is coolant supplied to the machines you work with:
Central coolant supply only
Each machine has its own coolant supply
Some have a central and some have their own coolant supply
Do you wear gloves at work?
Yes, all the time
Yes, some of the time
No, never
If yes:
What
type of glove(s) do you wear most often? (Check all that apply.) □ Synthetic
rubber (e.g., nitrile, neoprene, etc.) □ Natural
rubber or latex □ Plastic
(e.g., vinyl, PVC, polyethylene) □ Cotton
or cloth gloves
□ Leather □ Other
(describe: ________________________________) What
type of glove do you wear most often next
to your skin?
Please answer this question whether or not you wear one or two pairs
of gloves at the same time. (Check only one box.) □ Synthetic
rubber (e.g., nitrile, neoprene, etc.) □ Natural
rubber or latex □ Plastic
(e.g., vinyl, PVC, polyethene) □ Cotton
gloves underneath rubber or plastic gloves □ Cloth,
other than cotton □ Leather □ Other
(describe: ________________________________)
On average, how many times per shift do you wash your hands with soap and water?
_____ times per shift
On average, how many times per shift do you use hand-wipes to clean your hands?
_____ times per shift
Do you use solvents such as mineral spirits, rubbing alcohol, or kerosene to clean your hands at work?
No Yes
If yes:
On
average, how many times per shift do you clean your hands with
solvents? ____
times per shift
Do you apply moisturizing lotion to your hands or arms at work?
No Yes
If yes:
On
average, how many times per shift do you apply moisturizing lotion? ____
times per shift
Barrier
creams are used to prevent chemicals from penetrating
the
skin.
Do you apply barrier cream at work?
No Yes
If yes:
On
average, how many times per shift do you apply barrier cream? _____
times per shift
Outside of your job at this facility, have you worked with any of the following on a regular basis in the past 12 months? (Check all that apply.)
Hydraulic or engine oils, lubricants or oily metal parts
Solvents (any type)
Paints, primers, or glaze
Industrial strength cleaning agents
Glues, adhesives, tape, etc.
Sealants or caulks
Ceramic, plaster, or cement
Pesticides, herbicides, or fertilizers
Wood
Other (specify :_____________________________________)
I haven’t worked with any of these in the past 12 months
Have you ever had an itchy rash that comes and goes for at least 6 months, and at some time has affected skin creases? (by creases we mean inside of elbows, behind the knees, fronts of ankles, around the neck, ears, or eyes)
No Yes
For questions 22-28, please use the following definition:
Dermatitis
is a skin irritation or rash with red, dry skin that can have tiny
bumps or blisters, flaking, cracks, or crusts. The skin often
itches, burns, or stings.
Have you had dermatitis at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?
On your hands or fingers? No * Yes **
On your wrists or forearms? No * Yes **
On your face or neck? No * Yes **
*If no to all three items in question 22, go to question 29.
**If yes to any, please continue with question 23.
23. Do you have dermatitis now?
No Yes
If no:
When you were away from work for more than 5 days was your
dermatitis: Better The
same Worse
If yes:
When you are away from work for more than 5 days is your dermatitis: Better The
same Worse
24. In the past 12 months, have you changed glove type because of your dermatitis?
No Yes
I
What
type of glove(s) did you stop wearing because of your dermatitis?
___________________________________________________________
25. In the past 12 months, did you begin to wear gloves because of your dermatitis?
No Yes
26. Did you have to change jobs due to your dermatitis?
No Yes
If yes:
After
changing jobs was your dermatitis: Better The
same Worse
27. What do you think was the cause of your dermatitis?
_____________________________________________________________________________
28. Have you seen a doctor for your dermatitis at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?
No Yes
If yes:
Did
the doctor do any of the following tests to diagnose your
dermatitis? Check all that apply. Blood
test Skin
patch test Skin
prick, puncture, or scratch test Other
(specify: ___________________________________) No
tests were done to make the diagnosis What
did the doctor say that you had? Check all that apply. Allergic
contact dermatitis (Allergic to what? ____________________) Irritant
contact dermatitis Other
(specify: ____________________________________) Don’t
know Did
the doctor say the dermatitis was related to your job? No
Yes Maybe
In what season do you have the most problems with dermatitis? (Check only one box.)
Winter
Spring
Summer
Fall
No seasonal difference
All employees continue with Question 29
Have you had wheezing or whistling in your chest at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?
No Yes
If yes:
Have
you been at all breathless when the wheezing or whistling noise was
present?
No
Yes Have
you had this wheezing or whistling when you did not have a cold?
No
Yes
When
you are away from work on days off or vacation, is this wheezing or
whistling: Better The
same Worse
Have you been woken up with a feeling of tightness in your chest at any time in the last 12 months (or since beginning your current position if in that position less than 12 months)?
No Yes
If yes:
When
you are away from work on days off or on vacation, are your episodes
of chest tightness: Less
often The
same More
often
Have you ever had asthma?
No Yes
If yes:
Did
your asthma start after you began working in your current job title?
No
Yes Have
you had an attack of asthma in the last 12 months (or since
beginning your current position if in that position less than 12
months)?
No
Yes
If
yes,
When
you are away from work on days off or on vacation, are your attacks
of asthma:
Less
often
The
same
More
often
Are you currently taking any medicine (including inhalers or pumps, aerosols, or tablets) for asthma?
No Yes
If yes:
When
you are away from work on days off or on vacation, do you take the
medicine for asthma: Less
often The
same More
often
Have you ever had “hay fever” or other symptoms of nasal allergy?
No Yes
In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had a problem with sneezing, runny nose, or blocked nose when you did not have a cold or flu?
No Yes
I
When you are away from work
on days off or on vacation, is this problem:
Better
The
same
Worse
In
the last 12 months, has this nose problem been accompanied by itchy,
watery eyes?
No
Yes
In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had more than one episode of illness with at least 2 of the following symptoms?
Cough
Wheeze
Shortness of breath
Chest tightness
No Yes
If yes:
Were
these episodes combined with fever or weight loss? No
Yes
In the last 12 months (or since beginning your current position if in that position less than 12 months) have you had pneumonia or chest flu?
No Yes
If yes:
How
many times have you had pneumonia or chest flu in the last 12 months
(or since beginning your current position if in that position less
than 12 months)? __________times
What is your smoking history?
Never
smoked means fewer than 20 packs of cigarettes in a lifetime or
less than 1 cigarette a day for 1 year.
Never smoked
Former smoker
Current smoker
Thank you for your participation!
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