Form Approved
OMB No. 0920-1154
Exp. Date 03/31/2026
Instructions: Please answer the following demographic questions.
Where is the mine(s) you work at located (state)? _________________________________
What is the primary commodity produced at your mine(s)? _________________________
What type of operation is it? (Pick all that apply):
☐ Underground mine
☐ Surface mine
☐ Preparation / Processing Plant
☐ Office
☐ Other __________________________________________
What is your current job title: _____________________________
Number of years in your current job title: __________ years
Number of years at your current mine: __________ years
Number of years of total mining experience: __________ years
Age: __________ years
Education (select one):
○ Less than high school
○ High school/GED
○ Some college
○ Bachelor’s degree or higher
○ Prefer not to answer
Race/Ethnicity (select all that apply):
☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Hispanic or Latino
☐ Middle Eastern or North African
☐ Native Hawaiian or Pacific Islander
☐ White
☐ Other
☐ Don’t know
☐ Prefer not to answer
What is your sex?
☐ Female
☐ Male
What was your entire household income last year before taxes?
☐ <$20,000
☐ $20,000 to $34,999
☐ $35,000 to $49,999
☐ $50,000 to $74,999
☐ $75,000 to $99,999
☐ $100,000 to $149,999
☐ $150,000 to $199,999
☐ $200,000 or more
☐ Prefer not to answer
Are you the head of your household?
☐ Yes
☐ No
☐ Prefer not to answer
What is your current marital status?
☐ Divorced
☐ Married or living with partner
☐ Never married
☐ Separated
☐ Widowed
☐ Prefer not to answer
How many dependents currently live in your household? Please enter the total number in each age category.
Total number of household members aged 0 to 5: __________
Total number of household members aged 6 to 12: __________
Total number of household members aged 13 to 17: __________
Total number of household members aged 18 or older: __________
Public reporting burden of this collection of information is estimated to average XX 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 Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Dugdale, Zoe (CDC/NIOSH/SMRD/MHB) |
File Modified | 0000-00-00 |
File Created | 2025-07-04 |