Form 0920-0260 HHE Specific Worker Interview - example

Attachment D

Sample HHE Specific Worker Interview

Form Approved

OMB No. 0920-0260

Expires xx/xx/xxxx

Northport VAMC Employee Interview

1. Name: _________________________________________________

2. Sex ______ 3. Age ___________

4. Employer (circle): VA Contractor/other: ___________

5. Year of hire: __________

6. Current Position: ____________________________________________________

6a. Supervisory? [ ] yes [ ] no

7. How long in this position? ________

7a. If less than 1yr, prior position at VA? _________________________________

8. Current Work Area (location where the majority of your work is done)

___________________________________________________________________

9. Description of Work Tasks: ____________________________________________

_____________________________________________________________________

10. Do you wear any PPE not required at work? [ ]yes [ ]no

If yes, type/why: ____________________________________

11. Any/type of workplace medical evaluation? __________________________________

12. Any concerns about work exposures? [ ] yes [ ] no

If yes, what concerns? _________________________________________________

13. Do you have any health problems you think are related to work at Northport VAMC?

[ ]yes [ ]no [ ] unsure ***IF NO, SKIP TO QU# 17***

Health problem Onset reported to spvr? Saw Dr? (consent)

________________________________________________________________________

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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0260). Do not send the completed form to this address.

15. Did you change your work area due to a health problem? [ ] yes [ ] no

16. What do you think your symptoms or health problems are/were caused by?

17. Do you have any allergies? [ ] no [ ] yes IF yes, to what? _______________________

18. Do you have: asthma? [ ] yes [ ] no

atopic eczema? [ ] yes [ ] no

19. Do you smoke? [ ] yes, currently [ ] not now but in past [ ] no, never

20. Do you have any chronic health problems you are followed by a doctor or take medication for? [ ] yes [ ] no

If yes, please explain: _________________________________________________________

______________________________________________________________________________

21. Please list any medication that you take regularly: ________________________________

22. Do you have any of the following symptoms during work hours currently? (Circle)

Eye irritation

Nasal irritation

Throat irritation

Headache

Shortness of breath

Chest tightness

Cough

Wheeze

Nausea

Lightheaded or Dizzy

Other:

22a. mark “I” next to symptom if it improves on days off.

23. Are any of these symptoms seasonal? [ ] no [ ] yes If yes, which ones?

24. Have you had a skin rash in the past month? If yes, explain history: ___________________________________________________________________________

25. Do you feel that your work environment is a comfortable temperature and humidity level?

[ ] yes [ ] no If no, explain: _____________________________________________________

26. Have you noticed black particles in your work area? [ ] yes [ ] no

If yes, when/where did you first notice them? _________________________________

How often do you see them? ______________________________________________

Related to any activities? _____________________________________________

27. Other health concerns related to work?