HHE Evaluation Ineview

Attachment E

Sample HHE Specific Worker Interview

Form Approved OMB

No. 0920-0260

Expires xx/xx/20xx

Jockey Lead Exposure Questionnaire

Name Age Gender

Height Weight

Mailing address:

Phone number:

How long have you been a jockey?

How many months a year do you race?

Approximate number of races ridden in last 6 months?

Do you do other work in addition to racing?

If so what and how often? Do you personally handle/place uncovered lead weights in your saddle?

If yes, what percentage of races do you use weights that you handle yourself?

If no, does the valet handle weights?

If no, do you use covered weights or weighted saddle blanket?

Do you transport lead weights from track to track?

If so, how do you transport them (box/bag)

Public reporting burden for 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 this collection of information including suggestions for reducing this burden to: CDC/ATSDR, Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA. (0920-0260).

Do children or other family members have access to your racing

equipment and saddles?

Do you shower after racing and before leaving the track?

Do you change clothes after racing and before leaving the track?

Have you ever had your blood lead level checked?

If so, what year and what were the results?

Potential non-racing exposure to lead

Have you participated in any of the following activities in the past year?

If so, approximately how often?

Construction

Home Remodeling/refinishing in homes built before 1980?

Painting (marine, industrial and artists paint)

Welding

Plumbing/lead soldering

Stain glass/glazed pottery making

Casting lead sinkers or bullet reloading

Target shooting at firing ranges

Hunting

Reloading of shells

Fishing

Use of lead sinkers/weights