App F_Screening Questionnaire

Appendix F

Screening Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Read to participant:

“Thanks you for expressing interest in participating in the study on boot wear that we are conducting through the Office of Mine Safety and Health Research (OMSHR) and the National Institute for Occupational Safety and Health (NIOSH). In an attempt to identify if you are eligible to participate in the study on boot wear, please answer the following questions:”

1. Do you have any known or diagnosed musculoskeletal or other deformities to the hip, knee, or ankle?

Yes / No

2. Have you ever been diagnosed with a lower extremity disorder?

Yes / No

3. Have you had a sprain/strain in your lower extremity in the past 6 months?

Yes / No

4. Have you experienced any chronic pain/discomfort in your lower extremity in the past 6 months?

Yes / No

5. Is there any reason why you would not be able to participate in a study that would last for a period of 24 months (two years)?

Yes / No

Interpreting results:

If the answer is ‘Yes’ to any questions the participant is not-eligible to participate in the study and can be told so.

If all answers are ‘No’ the following information can be communicated to the participant:

“You are eligible to participate in the study. This does not mean you are enrolled in the study. You will be provided additional details on the study and you can then decide if you would like to participate in the study.”

CDC estimates the average public reporting burden for this collection of information as 6 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).