0920-24AL Baseline Questionnaire

Form Approved

OMB No. XXX

Exp. Date XX/XX/XXXX

Baseline Questionnaire

Date: __ __ / __ __ / __ __ __ __ Unique ID: __________

(Month) (Day) (Year) (assigned by study personnel)

Section I: Screening

1. Have you worked at a clinical veterinary practice in any position

(including, but limited to, veterinarian; veterinary technologist,

nurse, technician, or assistant; kennel staff; grooming staff; office staff;

or environmental services staff) at any time during the past 12 months? 1.____ Yes 0. ____ No

IF YES: CONTINUE

IF NO: STOP

2. Date of Birth: __ __ / __ __ / __ __ __ __

(data collection system to calculate age) (Month) (Day) (Year)

IF >=18 years old: CONTINUE

IF <18 years old: STOP

Section II: Demographic Information

3. What is your race and/or ethnicity? One or more

categories may be selected. 1.___ American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

2.___ Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

3.___ Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

4.___ Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

5.___ Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

6.___ Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

7.___ White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

4. What is your current gender? One or more categories

may be selected. 1.___ Female

2.___ Male

3.___ Transgender

4.___ [If respondent marked AIAN] Two-Spirit

5.___ I use a different term

IF I USE A DIFFERENT TERM:

1. Describe: ___________________________________________________________

Public reporting burden of this collection of information is estimated to average 28 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-XXXX).

5. What sex were you assigned at birth, on your original birth

certificate? 1.____ Male 0. ____Female

6. What is the highest grade or level of school you have

completed or the highest degree received? 1.____ 8^th grade or less

2.____ 9^th-12^th grade (no diploma)

3.____ High school graduate (diploma)

4.____ GED or equivalent

5.____ Some college (no degree)

6.____ Associate’s degree: occupational, technical, or vocational program

7.____ Associate’s degree: academic (general education)

8.____ Bachelor’s degree (example: BA, AB, BS, BBA)

9.____ Master’s degree (example: MA, MS, MEng, Med, MBA)

10.___ Professional school degree (example: MD, DDS, DVM, JD)

11.___ Doctoral degree (example: PhD, EdD)

Section III: Current Health Information

The next set of questions are 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.”

7. During the past 12 months, have you had any trouble

with your breathing? 1.____ Yes 0. ____ No

IF YES:

1. 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.

2. When you are away from clinical veterinary practice on days

off or on vacation, is the trouble with your breathing: 1.___ The same

2.___ Worse

3.___ Better

3. During the past 4 weeks, have you had any trouble

with your breathing? 1.____ Yes 0. ____ No

8. Are you troubled by shortness of breath when hurrying

on level ground or walking up a slight hill? 1.____ Yes 0. ____ No

IF YES:

1. Do you get short of breath walking with people of

your own age on level ground? 1.____ Yes 0. ____ No

2. Do you ever have to stop for breath when walking

at your own pace on level ground? 1.____ Yes 0. ____ No

3. Do you ever have to stop for breath after walking about

100 yards (or after a few minutes) on level ground? 1.____ Yes 0. ____ No

4. In what month and year did your breathlessness start? __ __ / __ __ __ __

(Month) (Year)

9. Do you usually have a cough? 1.____ Yes 0. ____ No

(Count cough with first smoke or on first going out-of-doors.

Exclude clearing of throat.)

IF YES:

1. Do you usually cough on most days for 3

consecutive months or more during the year? 1.____ Yes 0. ____ No

2. In what month and year did this cough begin? __ __ / __ __ __ __

(Month) (Year)

3. When you are away from clinical veterinary practice on days

off or on vacation, is your cough: 1.___ The same

2.___ Worse

3.___ Better

4. Is there anything at the clinical veterinary practice that causes or

aggravates this cough? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

5. Have you had a cough at any time in the last 4 weeks? 1.____ Yes 0. ____ No

10. Do you bring up phlegm on most days for 3

consecutive months or more during the year? 1.____ Yes 0. ____ No

11. Have you had wheezing or whistling in your chest at

any time in the last 12 months? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, is this wheezing or whistling: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates this wheezing or whistling? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had wheezing or whistling in your chest

at any time in the last 4 weeks? 1.____ Yes 0. ____ No

12. 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:

1. When you are away from clinical veterinary practice on days

off or on vacation, is this chest tightness: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates this chest tightness? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you woken up with a feeling of tightness in

your chest at any time in the last 4 weeks? 1.____ Yes 0. ____ No

13. Have you been woken by an attack of shortness of breath at

any time in the last 12 months? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these attacks of shortness of breath: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these attacks of shortness of breath? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you been woken by an attack of shortness of

breath at any time in the last 4 weeks? 1.____ Yes 0. ____ No

14. Have you had an attack of asthma in the last 12 months? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these attacks of asthma: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these attacks of asthma? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had an attack of asthma in the last 4 weeks? 1.____ Yes 0. ____ No

15. Are you currently taking any medicine including inhalers,

aerosols, or tablets for asthma? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, do you take the medicine for asthma: 1.___ The same

2.___ More Often

3.___ Less Often

16. Are you currently taking any medicine including inhalers,

aerosols, or tablets for other breathing problems? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, do you take the medicine for other

breathing problems: 1.___ The same

2.___ More Often

3.___ Less Often

17. During the past 12 months, have you had episodes of a

stuffy, itchy, or runny nose? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these nose symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these nose symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had episodes of a stuffy, itchy,

or runny nose in the past 4 weeks? 1.____ Yes 0. ____ No

18. During the past 12 months, have you had episodes of a

stinging or burning nose? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these nose symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these nose symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had episodes of a stinging or burning

nose in the past 4 weeks? 1.____ Yes 0. ____ No

19. During the past 12 months, have you had a problem with sneezing,

or a runny, or blocked nose when you did not have a cold or the flu? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these nose symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these nose symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had a problem with sneezing, or a runny, or

blocked nose when you did not have a cold or the flu in

the past 4 weeks? 1.____ Yes 0. ____ No

20. During the past 12 months, have you had sinusitis

or sinus problems? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these sinus problems: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these sinus problems? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had sinusitis or sinus problems

in the past 4 weeks? 1.____ Yes 0. ____ No

21. During the past 12 months, have you had hoarseness or a dry, sore,

or burning throat? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these throat symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these throat symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had hoarseness or a dry, sore, or burning throat

in the past 4 weeks? 1.____ Yes 0. ____ No

22. During the past 12 months, have you had episodes of

watery, itchy eyes? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these eye symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these eye symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had episodes of watery, itchy

eyes in the past 4 weeks? 1.____ Yes 0. ____ No

23. During the past 12 months, have you had episodes of

stinging or burning eyes? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these eye symptoms: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these eye symptoms? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had episodes of stinging or burning

eyes in the past 4 weeks? 1.____ Yes 0. ____ No

24. During the past 12 months, have you had frequent or severe

headaches, including migraines? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these headaches: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these headaches? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had frequent or severe headaches, including

migraines, in the past 4 weeks? 1.____ Yes 0. ____ No

25. During the past 12 months, have you had episodes of fever,

chills, or flu-like achiness? 1.____ Yes 0. ____ No

IF YES:

1. When you are away from clinical veterinary practice on days

off or on vacation, are these episodes of fever, chills, or

flu-like achiness: 1.___ The same

2.___ Worse

3.___ Better

2. Is there anything at the clinical veterinary practice that causes or

aggravates these episodes of fever, chills, or

flu-like achiness? 1.____ Yes 0. ____ No

IF YES:

1. Describe:________________________________________________________

3. Have you had episodes of fever, chills, or flu-like

achiness in the past 4 weeks? 1.____ Yes 0. ____ No

26. Have you ever been told by a physician or other health professional that you had any of the following conditions? (Select all that apply.)

Conditions	Month and year of first diagnosis?	Thought to be work-related?
1. ____ Hay fever or nasal allergies	__ __ / __ __ __ __	1.____ Yes 0. ____ No
2. ____ Animal-related allergies	__ __ / __ __ __ __	1.____ Yes 0. ____ No
3. ____ Eczema, dermatitis, or skin allergy	__ __ / __ __ __ __	1.____ Yes 0. ____ No
4. ____ Heart disease	__ __ / __ __ __ __	1.____ Yes 0. ____ No
5. ____ Gastroesophageal reflux disease (GERD)	__ __ / __ __ __ __	1.____ Yes 0. ____ No
6. ____ Sinusitis or sinus infections	__ __ / __ __ __ __	1.____ Yes 0. ____ No
7. ____ Chronic bronchitis	__ __ / __ __ __ __	1.____ Yes 0. ____ No
8. ____ Emphysema	__ __ / __ __ __ __	1.____ Yes 0. ____ No
9. ____ Chronic obstructive pulmonary disease (COPD)	__ __ / __ __ __ __	1.____ Yes 0. ____ No
10. ____ Hypersensitivity pneumonitis	__ __ / __ __ __ __	1.____ Yes 0. ____ No
11. ____ Chemical pneumonitis	__ __ / __ __ __ __	1.____ Yes 0. ____ No
12. ____ Sarcoidosis	__ __ / __ __ __ __	1.____ Yes 0. ____ No
13. ____ Interstitial lung disease	__ __ / __ __ __ __	1.____ Yes 0. ____ No
14. ____ Asthma	__ __ / __ __ __ __	1.____ Yes 0. ____ No
IF YES: 14.1 Do you still have asthma?	1.____ Yes 0. ____ No	1.____ Yes 0. ____ No
15. ____ Cancer	1.____ Yes 0. ____ No
IF YES: 15.1 What type of cancer(s)? __________________________________________________ 15.2 Month and year of first diagnosis(es)? _________________________________________

27. Have you ever been told by a physician or other health

professional that you had any other respiratory condition

(infectious or non-infectious)? 1.____ Yes 0. ____ No

IF YES:

(online questionnaire to allow multiple entries)

1. What was the diagnosis: _______________________________________________

2. Was this condition suspected to be work-related? 1.____ Yes 0. ____ No

3. In what month and year were you first given this

respiratory condition diagnosis? __ __ / __ __ __ __

(Month) (Year)

IF YES to QUESTION #14 (attack of asthma in the last 12 months) or QUESTION #26.14 (Asthma):

28. Since you began working in a veterinary clinic setting,

is your asthma: 1.___ The same

2.___ Worse

3.___ Better

29. Have you ever had to change your veterinary work duties

because of your asthma? 1.____ Yes 0. ____ No

IF YES:

1. Describe: ______________________________________________________________

IF YES to QUESTION #26.1 (Hay fever or nasal allergies) or QUESTION #26.2 (Animal-related allergies):

30. Since you began working in a veterinary clinic setting,

are your allergies: 1.___ The same

2.___ Worse

3.___ Better

31. Have you ever had to change your veterinary work duties

because of your allergies? 1.____ Yes 0. ____ No

IF YES:

1. Describe: ______________________________________________________________

Section IV. Tasks and Related Potential Hazards

The next set of questions are about tasks and related potential hazards at work.

32. During an average work week, are you exposed to surgical smoke

generated during electrosurgery (including electrocautery,

diathermy, and ultrasonic devices)? 1.____ Yes 0. ____ No

IF YES:

1. When was the last time you received training that addresses

the hazards of surgical smoke? 1.____ Within the past 12 months

2.____ More than 12 months ago

3.____ I never received training

2. Does your employer have standard procedures that

address potential hazards of surgical smoke? 1.___ Yes 0. ___ No 2. ___ Don’t Know

3. At any time in the past 7 calendar days, did you work within

5 feet of the source of surgical smoke during electrosurgery?

(Electrosurgery includes electrocautery, diathermy, and

ultrasonic devices.) 1.____ Yes 0. ____ No

IF YES:

Local Exhaust Ventilation (LEV) captures and removes contaminants at the point where they are being produced, such as a portable exhaust system with high efficiency particulate filters, or a flexible tube connected to a room (wall) suction system. LEV does not include blood suction canister systems.

Electrosurgery includes electrocautery, diathermy, and ultrasonic devices.

1. During the past 7 calendar days, how often was LEV

(e.g., portable smoke evacuator or room [wall] suction

system) used while you worked within 5 feet of the

source of surgical smoke during electrosurgery? 1.____ Always

2.____ Sometimes

3.____ Never

IF ALWAYS OR SOMETIMES:

1. During the past 7 calendar days, what type

of LEV was used while you worked within

5 feet of the source of surgical smoke

during electrosurgery?

(Select all that apply) 1.____ Portable smoke evacuator

2.____ Room (wall) suction system

IF SOMETIMES OR NEVER:

2. What was the reason(s) LEV was not

always used during electrosurgery?

(Select all that apply) 1.____ General room ventilation was sufficient to dissipate smoke plume

2.____ Used a different system (e.g., blood suction canister) to remove the smoke

3.____ Exposure was minimal

4.____ Not part of our protocol

5.____ Not provided by employer

6.____ No one else who does this work uses them

7.____ Too difficult to use

8.____ Too bulky or noisy

9.____ Not readily available in work area

10.___ Not permitted by surgeon

11.___ Other (specify)

IF MORE THAN ONE REASON CHECKED:

1. Of the reasons you checked

above, please indicate the most

important reason local exhaust

ventilation was not always

used. (Select one) 1.____ General room ventilation was sufficient to dissipate smoke plume

2.____ Used a different system (e.g., blood suction canister) to remove the smoke

3.____ Exposure was minimal

4.____ Not part of our protocol

5.____ Not provided by employer

6.____ No one else who does this work uses them

7.____ Too difficult to use

8.____ Too bulky or noisy

9.____ Not readily available in work area

10.___ Not permitted by surgeon

11.___ Other (specify)

33. Do you perform mask or chamber induction using an inhalational

anesthetic (e.g., Sevoflurane or Isoflurane)? 1.____ Yes 0. ____ No

34. Do you work with animals that are under general

anesthesia, or recovering from general anesthesia, using an

inhalational anesthetic (e.g., Sevoflurane or Isoflurane) 1.____ Yes 0. ____ No

35. How often do you detect the odor of an inhalational anesthetic? 1.____ Never

2.____ Sometimes

3.____ Frequently

36. Is there a waste anesthetic gas scavenging system

at the clinical veterinary practice? 1.___ Yes 0. ___ No 2. ___ Don’t Know

IF YES:

1. When is the waste anesthetic gas scavenging

system checked for proper functioning? 1.____ Before each anesthetic procedure

2.____ Before starting anesthetic procedures each day

3.____ Daily, but not necessarily before starting anesthetic procedures each day

4.____ Weekly

5.____ Don’t know

6.____ Other (specify):________________

2. Is there a waste anesthetic gas scavenging

system preventive maintenance program? 1.___ Yes 0. ___ No 2. ___ Don’t Know

IF YES:

1. Who performs the preventive

maintenance? (Select all that apply.) 1.____ Contractor

2. ____ Myself

3. ____ Lead technician

4. ____ Chief of staff (veterinarian)

5. ____ Any staff veterinarian

6. ____ Office manager

7. ____ Don’t know

8.____ Other (specify):___________

37. During an average work week, do you use cleaning, disinfecting,

or sterilizing agents at your veterinary clinic? 1.____ Yes 0. ____ No

IF YES:

1. Do you clean, disinfect, or sterilize any of the

following at your veterinary clinic?

(Select all that apply.) 1.____ Animal cages, kennels, or runs

2.____ Litter boxes

3.____ Bird cages

4.____ Barn stalls

5.____ Other area(s) containing animal wastes (specify)

6.____ Medical equipment/instruments

7.____ Surfaces, such as examination tables, surgery tables, and counters

FOR EACH SELECTED:

1. What cleaning product(s) do you use most often

when performing this cleaning, disinfecting, or

sterilizing? (Brand names or chemical names

are acceptable.) ______________________

38. During an average workday, do you breathe in motor

vehicle exhaust? 1.____ Yes 0. ____ No

39. Do you perform any other task(s) at your veterinary clinic

that you feel expose you to respiratory hazards? 1.____ Yes 0. ____ No

IF YES:

1. Describe the task(s) and respiratory hazard(s): ____________________________________

Section V. Personal Protective Equipment

The next set of questions are about personal protective equipment (PPE) use.

IF QUESTION #32.3 is YES (any time in the past 7 calendar days worked within 5 feet of the source of surgical smoke during electrosurgery):

40. During the past 7 calendar days, how often did you wear

protective gloves during electrosurgery? 1.____ Always

2.____ Sometimes

3.____ Never

41. During the past 7 calendar days, how often did you wear eye

protection while you worked within 5 feet of the source of

surgical smoke during electrosurgery? Examples of eye

protection include goggles and safety glasses. Do not include

personal eye glasses. 1.____ Always

2.____ Sometimes

3.____ Never

IF SOMETIMES OR NEVER:

1. What are the reason(s) you did not always wear eye

protection during electrosurgery? (Select all that apply) 1.____ An engineering control (e.g., local exhaust ventilation) was being used

2.____ Exposure was minimal

3.____ Not part of our protocol

4.____ Not provided by employer

5.____ No one else who does this work uses them

6.____ Too uncomfortable or difficult to use

7.____ Not readily available in work area

8.____ Other (specify)

IF MORE THAN ONE REASON CHECKED:

1. Of the reasons you selected, please indicate the

most important reason you did not always wear

eye protection during electrosurgery. (Select one) 1.____ An engineering control (e.g., local exhaust ventilation) was being used

2.____ Exposure was minimal

3.____ Not part of our protocol

4.____ Not provided by employer

5.____ No one else who does this work uses them

6.____ Too uncomfortable or difficult to use

7.____ Not readily available in work area

8.____ Other (specify)

42. During the past 7 calendar days, did you wear any of the following during electrosurgery? (Select all that apply)

1.____ N95 respirator (including surgical N95 respirator)	2.____ Half-facepiece air purifying respirator with particulate filter(s)	3.____ Powered air purifying respirator (PAPR) with particulate filter(s)
4.____ Standard surgical mask	5.____ Laser mask	6.____ Other (specify) ____________________
7.____ I did not wear any respirators or masks	8.____ I don’t know

IF N95 RESPIRATOR, HALF-FACEPIECE, OR PAPR SELECTED:

1. How often did you wear a N95 respirator, half-facepiece

air purifying respirator with particulate filter(s), or powered

air purifying respirator with particulate filter(s) during

electrosurgery? 1.____ Always

2.____ Sometimes

IF N95 RESPIRATOR OR HALF-FACEPIECE SELECTED:

2. Have you been fit-tested for the respirator(s) you use

during electrosurgery? 1.____ Yes 0. ____ No

IF QUESTION #42 is “I did not wear any respirators or masks” OR QUESTION #42.1 is SOMETIMES:

3. What were the reason(s) you did not always wear a N95

respirator, a half-facepiece air purifying respirator with

particulate filter(s), or a powered air purifying respirator

with particulate filter(s) during electrosurgery?

(Select all that apply) 1.____ An engineering control (e.g., local exhaust ventilation) was being used

2.____ Exposure was minimal

3.____ Not part of our protocol

4.____ Not provided by employer

5.____ No one else who does this work uses them

6.____ Too uncomfortable or difficult to use

7.____ Not readily available in work area

8.____ Other (specify)

IF MORE THAN ONE REASON CHECKED:

1. Of the reasons you selected, please indicate the

most important reason you did not always wear

a respirator during electrosurgery. (Select one) 1.____ An engineering control (e.g., local exhaust ventilation) was being used

2.____ Exposure was minimal

3.____ Not part of our protocol

4.____ Not provided by employer

5.____ No one else who does this work uses them

6.____ Too uncomfortable or difficult to use

7.____ Not readily available in work area

8.____ Other (specify)

FOR EACH ITEM SELECTED in QUESTION #37.1 (items cleaned, disinfected, or sterilized):

43. What PPE do you typically wear when performing cleaning, disinfecting, or sterilizing of:

Only show/complete for items cleaned, disinfected, or sterilized from QUESTION #37.1.	Select all that apply:
Animal cages, kennels, or runs	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify): _________________
Litter boxes	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________
Bird cages	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________
Barn stalls	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________
Other area(s) containing animal wastes (specify) _________________________	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________
Medical equipment/instruments	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________
Surfaces, such as examination tables, surgery tables, and counters	1.____ Gloves 2.____ Goggles 3.____ Surgical mask 4.____ Face shield 5.____ Gown or apron 6.____ Other (specify) : _________________

Section VI. Work Information

The next set of questions are about your workplace and work history.

44. Where do you currently work (facility name)? ___________________________

(online questionnaire to allow choice of participating facilities)

45. When did you start working at this facility? __ __ / __ __ __ __

(Month) (Year)

46. What is your current position in clinical

veterinary practice? (Select one.) 1.____ Veterinarian (Owner/Partner)

2.____ Veterinarian (Associate)

3.____ Veterinarian (Relief)

4.____ Veterinary technologist

5.____ Veterinary technician

6.____ Veterinary assistant

7.____ Student (veterinary school)

8.____ Student (veterinary technology school)

9.____ Student (veterinary technician school)

10.____ Office staff

11.____ Kennel help

12.____ Volunteer

13.____ Other (specify)

IF Veterinarian (Owner/Partner), (Associate), (Relief):

1. What year did you graduate veterinary school? __ __ __ __

(Year)

IF Veterinary technologist:

2. What year did you graduate veterinary technologist school? __ __ __ __

(Year)

3. Are you credentialed by your

state (i.e., possess an RVT, LVT, or CVT)? 1.____ Yes 0. ____ No

IF Veterinary technician:

4. What year did you graduate veterinary technician school? __ __ __ __

(Year)

5. Are you credentialed by your

state (i.e., possess an RVT, LVT, or CVT)? 1.____ Yes 0. ____ No

47. When did you first start working (or volunteering) in any

veterinary clinic setting? __ __ / __ __ __ __

(Month) (Year)

48. Have you ever worked in a veterinary clinic setting outside of

the United States? 1.____ Yes 0. ____ No

IF YES:

1. In what country(ies) did you work in a veterinary

clinic setting? _____________________

2. When did you work there? ______________________________

49. On average, how many hours per day do you currently work? ________ hours

50. On average, how many days per week do you currently work? ________ days

51. At your veterinary clinic, what types of animals are treated…

…by any veterinary personnel? (Select all that apply.) (If you work at multiple clinics, choose the practice type for the clinic where you work the most number of hours per week.)	…by you? (Select all that apply.) (If you work at multiple clinics, choose the practice type for the clinic where you work the most number of hours per week.)
1.____ Cats	1.____ Cats
2.____ Dogs	2.____ Dogs
3.____ Rabbits	3.____ Rabbits
4.____ Ferrets	4.____ Ferrets
5.____ Small rodents (e.g., rats, mice, hamsters)	5.____ Small rodents (e.g., rats, mice, hamsters)
6.____ Other pocket pets (e.g., sugar gliders, hedgehogs, chinchillas)	6.____ Other pocket pets (e.g., sugar gliders, hedgehogs, chinchillas)
7.____ Horses	7.____ Horses
8.____ Cattle (dairy or beef)	8.____ Cattle (dairy or beef)
9.____ Sheep	9.____ Sheep
10.____ Goats	10.____ Goats
11.____ Pigs	11.____ Pigs
12.____ Camelids (llamas, alpacas)	12.____ Camelids (llamas, alpacas)
13.____ Birds (non-poultry)	13.____ Birds (non-poultry)
14.____ Poultry	14.____ Poultry
15.____ Reptiles or amphibians	15.____ Reptiles or amphibians
16.____ Wildlife	16.____ Wildlife
17.____ Non-human primates	17.____ Non-human primates
18.____ Zoo animals	18.____ Zoo animals
19.____ Other (specify)	19.____ Other (specify)

52. Does your veterinary clinic have a fragrance-free

policy? 1.___ Yes 0. ___ No 2. ___ Don’t Know

53. Do you regularly interact with animals outside of your

veterinary clinic (e.g., pets at home, other non-veterinary

jobs, recreational horse riding, etc.)? 1.____ Yes 0. ____ No

IF YES:

1. What species do you regularly interact with outside

of your veterinary clinic? (Select all that apply.) 1.____ Cats

2.____ Dogs

3.____ Rabbits

4.____ Ferrets

5.____ Small rodents (e.g., rats, mice, hamsters)

6.____ Other pocket pets (e.g., sugar gliders, hedgehogs, chinchillas)

7.____ Horses

8.____ Cattle (dairy or beef)

9.____ Sheep

10.____ Goats

11.____ Pigs

12.____ Camelids (llamas, alpacas)

13.____ Birds (non-poultry)

14.____ Poultry

15.____ Reptiles or amphibians

16.____ Wildlife

17.____ Non-human primates

18.____ Zoo animals

19.____ Other (specify)

Section VII: Workplace Safety Climate

Please indicate how much you agree or disagree with each of the following statements about safety practices at your workplace.

	Strongly Disagree (1)	Somewhat Disagree (2)	Somewhat Agree (3)	Strongly Agree (4)	Does Not Apply (-99)
A. Management reacts quickly to solve the problem when told about safety hazards
B. Management insists on thorough and regular safety audits and inspections
C. Management provides all the equipment needed to do the job safely.
D. Management invests a lot of time and money in safety training for workers.
E. Management listens carefully to workers’ ideas about improving safety.
F. Management gives safety personnel the power they need to do their job.

Section VIII: Stress

The next two questions are about stress. Stress means a situation in which a person feels tense, restless, nervous or anxious, or is unable to sleep because his/her mind is troubled all the time.

54. During the past 4 weeks, including today, how would you rate

your stress outside of work on a scale from 0 (as low as it can

be) to 10 (as high as it can be)? ________ rating

(online questionnaire to display stress thermometer image)

55. During the past 4 weeks, including today, how would you rate

your stress at work on a scale from 0 (as low as it can be) to

10 (as high as it can be)? ________ rating

(online questionnaire to display stress thermometer image)

Section IX: Tobacco Use Information

The next questions are about tobacco use.

56. 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:

1. How old were you when you first started

smoking regularly? ________ years

2. Over the entire time that you have smoked,

what is the average number of cigarettes

you smoked per day? ________ cigarettes/day

3. Do you still smoke cigarettes? 1.____ Yes 0. ____ No

IF NO:

1. How old were you when you stopped

smoking cigarettes regularly? ________ years

IF prior to any site visit to facility:

Thank you for your participation in the baseline questionnaire of this study on surgical smoke in veterinary clinical settings.

We will be at [facility name] on [dates], and for every day that you are working during that time, you will be invited to participate in the brief, post-shift questionnaire that will ask about respiratory and eye symptoms you had during your shift. Each post-shift questionnaire should take approximately 8 minutes or less. We thank you for your participation today, and look forward to seeing you when we are at [facility name] soon!

IF after final site visit to facility:

Thank you for your participation in this study on surgical smoke in veterinary clinical settings.