Attachment 3
Questionnaire
Form Approved OMB
NO. 0920-xxxx Expiration
Date: xx/xx/20xx
ID: _______________
NORA_FY2019
Styrene-Exposed
Cohort
NIOSH-Administered Former Employee Health Questionnaire
Interviewer: _______________ Interview Date: __ __ / __ __ / __ __ __ __
(Month) (Day) (Year)
Section I: Identification and Demographic Information
Name: ______________________ _____________________ ____
(Last Name) (First Name) (M.I.)
Address: ___________________________________________________
(Number, Street, and/or Rural Route)
___________________________ ___________ _________
(City) (State) (Zip Code)
Primary Telephone Number: (____) - ____ - ______ [ ] Home [ ] Cell
If you were to move, is there someone who would know how to contact you?
Name: ______________________ _____________________ ____
(Last Name) (First Name) (M.I.)
Relationship to you: ____________________________
Address: ___________________________________________________
(Number, Street, and/or Rural Route)
___________________________ ___________ _________
(City) (State) (Zip Code)
Primary Telephone Number: (____) - ____ - ______ [ ] Home [ ] Cell
Public
reporting burden of this collection of information is estimated to
average 45 mins 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-xxxx).
Date of Birth: __ __ / __ __ / __ __ __ __
(Month) (Day) (Year)
Sex: 1. ____ Male 0. ____Female
Are you Spanish, Hispanic or Latino? 1. ____ Yes 0. ____No
Select one or more of the following categories
to describe your race: 1.___ American Indian or Alaska Native
2.___ Asian
3.___ African-American or Black
4.___ Native Hawaiian or Other Pacific Islander
5.___ White
Section II: Health Information
I’m going to ask you some questions about your health. The answer to many of these questions will be “Yes” or “No.” If you are in doubt about whether to answer “Yes” or “No,” then please answer “No.”
During the past 12 months, have you had any trouble
with your breathing? 1.____ Yes 0. ____ No
IF YES:
Which of the following statements best describes
your breathing?
1.___ I only rarely have trouble with my breathing.
2.___ I have regular trouble with my breathing, but it always gets completely better.
3. ___ My breathing is never quite right.
In what month and year did the trouble with your
breathing first begin? __ __ / __ __ __ __
(Month) (Year)
Are you troubled by shortness of breath when hurrying on
level ground or walking up a slight hill? 1.____ Yes 0. ____ No
IF YES:
Do you get short of breath walking with other people of
your own age on level ground? 1.____ Yes 0. ____ No
Do you ever have to stop for breath when walking
at your own pace on level ground? 1.____ Yes 0. ____ No
Do you ever have to stop for breath after walking about
100 yards (or after few minutes) on level ground? 1.____ Yes 0. ____ No
Do you usually have a cough?
(Count cough with first smoke or on first going 1.____ Yes 0. ____ No
out-of-doors. Exclude clearing of throat.)
IF YES:
Do
you usually cough on most days for 3
consecutive months or
more during the year? 1.____ Yes 0. ____ No
In what month and year did this cough first begin? __ __ / __ __ __ __
(Month) (Year)
Do you bring up phlegm on most days for 3
consecutive months or more during the year? 1.____ Yes 0. ____ No
Have you had wheezing or whistling in your chest at
anytime in the last 12 months? 1.____ Yes 0. ____ No
IF YES:
In what month and year did this wheezing or
whistling first begin? __ __ / __ __ __ __
(Month) (Year)
Have you woken up with a feeling of tightness in your
chest at any time in the last 12 months? 1.____ Yes 0. ____ No
IF YES:
In what month and year did this chest tightness
first begin? __ __ / __ __ __ __
(Month) (Year)
Have you been woken by an attack of coughing
at any time in the last 12 months? 1.____ Yes 0. ____ No
IF YES:
In what month and year did these attacks of
coughing first begin? __ __ / __ __ __ __
(Month) (Year)
Have you had an attack of asthma in the last 12 months? 1.____ Yes 0. ____ No
IF YES:
In what month and year did these attacks of asthma
first begin? __ __ / __ __ __ __
(Month) (Year)
Are you currently taking any medicine including inhalers,
aerosols or tablets, for asthma? 1.____ Yes 0. ____ No
IF YES:
In what month and year did you first begin using
medicine for asthma? __ __ / __ __ __ __
(Month) (Year)
Are you currently taking any medicine including inhalers,
aerosols or tablets, for any other breathing problems? 1.____ Yes 0. ____ No
IF YES:
In what month and year did you first begin using
medicine for any other breathing problems? __ __ / __ __ __ __
(Month) (Year)
Have you ever been told by a physician that you had any of the following respiratory conditions?
Conditions |
Told by a physician you had? |
Month and Year of first diagnosis? |
1. Hay fever or nasal allergies |
1. Yes ___ 0. No ___ |
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2. Sinusitis or sinus infections |
1. Yes ___ 0. No ___ |
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3. Chronic bronchitis |
1. Yes ___ 0. No ___ |
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4. Emphysema |
1. Yes ___ 0. No ___ |
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5. Chronic obstructive pulmonary disease (COPD) |
1. Yes ___ 0. No ___ |
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6. Obliterative bronchiolitis |
1. Yes ___ 0. No ___ |
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7. Asthma |
1. Yes ___ 0. No ___ |
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7.1 IF YES: Do you still have asthma? |
1. Yes ___ 0. No ___ |
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Have you ever been told by a physician that you had
any other respiratory condition? 1.____ Yes 0.____ No
IF YES:
What was the diagnosis: _______________________________________________
In what month and year were you first given this
diagnosis? __ __ / __ __ __ __
(Month) (Year)
Have you ever had a lung biopsy? 1.____ Yes 0.____ No
IF YES:
What was the diagnosis: _____________________________________
In what month and year was the biopsy taken? __ __ / __ __ __ __
(Month) (Year)
What was the name of the hospital or health care facility where the biopsy was taken? _____________________________________
Now I am going to ask you about other health problems. Have you ever been told by a physician that you had any of the following conditions?
Conditions |
Told by a physician you had? |
Month and Year of first diagnosis? |
1. Hearing loss |
1. Yes ___ 0. No ___ |
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2. Cancer |
1. Yes ___ 0. No ___ |
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2.1 IF YES: What type of cancer? ________________________________________________
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Section III. Boatbuilding Work Information
I’m now going to ask you about your time working in the boatbuilding industry.
Where did you work? 1. ____Uniflite, Bellingham, WA
2. ____Tollycraft, Kelso, WA
3. ____Both
I’m now going to ask you to list all of the jobs that you have had while working at Uniflite or Tollycraft. What was the first job you held at Uniflite or Tollycraft?
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Job # |
Department |
Job Performed |
Start Date (mm/yyyy) |
End Date (mm/yyyy) |
Average Hours/Week |
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(Drop Down menus populated with lists)
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(Drop Down menus populated with lists)
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Did you wear breathing protection while at work?
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Section IV. Other Work Information
I’m now going to ask you about all the jobs you have worked since leaving Uniflite or Tollycraft. We will start with your most recent job and work back through time.
List all jobs that you had in any other boatbuilding facility since leaving Uniflite or Tollycraft.
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Job # |
Company name |
Location |
Department |
Job performed |
Start date (MM/YYYY) |
End Date (MM/YYYY) |
Average Hours/Week |
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List all other jobs NOT in boatbuilding that you had since leaving Uniflite or Tollycraft.
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Job # |
Company name |
Location |
Job title |
Start date (MM/YYYY) |
End Date (MM/YYYY) |
Avg. Hours/week |
Primary task |
Other task |
Styrene or styrene containing products |
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Section V: Tobacco and Marijuana Use Information
I’m now going to ask you a few questions about smoking.
Have you ever smoked cigarettes? 1. ___ Yes 0. ___ No
(NO if less than 20 packs of cigarettes in
a lifetime or less than 1 cigarette a day for 1 year)
IF YES:
How old were you when you first started
smoking regularly? ______ Years old
Over the entire time that you have smoked,
what is the average number of cigarettes
you smoked per day? ______ Cigarettes/day
Do you still smoke cigarettes? 1. ___ Yes 0. ___ No
IF NO:
23.3.1. How old were you when you stopped
smoking cigarettes regularly? ______ Years old
I’m now going to ask you a few questions about smoking marijuana.
During your life, have you smoked marijuana more than 50 times? 1. ___ Yes 0.___ No
IF Yes:
Have you smoked marijuana in the past 12 months? 1.___Yes 0.___No
IF Yes:
24.2.1. Have you smoked marijuana in the past 30 days? 1.___Yes 0.___No
Thank you for participating in this survey!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Tomasi, Suzanne (CDC/NIOSH/DSHEFS) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-10-06 |