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[OS] CDC/ATSDR Formative Research and Tool Development

Attachment D -- demographic and work history survey_030525

[NIOSH] Developing a Framework to Identify and Address Job Hazards Unique to Women Mine Workers

OMB: 0920-1154

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Form Approved

OMB No. 0920-1154

Exp. Date 03/31/2026


Demographic and Work History Survey


Instructions: Please answer the following demographic questions.


  1. Where is the mine(s) you work at located (state)? _________________________________

  2. What is the primary commodity produced at your mine(s)? _________________________

  3. What type of operation is it? (Pick all that apply):

Underground mine

Surface mine

Preparation / Processing Plant

Office

Other __________________________________________

  1. What is your current job title: _____________________________

  2. Number of years in your current job title: __________ years

  3. Number of years at your current mine: __________ years

  4. Number of years of total mining experience: __________ years

  5. Age: __________ years

  6. Education (select one):

Less than high school

High school/GED

Some college

Bachelor’s degree or higher

Prefer not to answer

  1. 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

  1. What is your sex?

Female

Male

  1. 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

  1. Are you the head of your household?

Yes

No

Prefer not to answer

  1. What is your current marital status?

Divorced

Married or living with partner

Never married

Separated

Widowed

Prefer not to answer

  1. 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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDugdale, Zoe (CDC/NIOSH/SMRD/MHB)
File Modified0000-00-00
File Created2025-07-04

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