Table A1:
Example Survey
| Item | Survey Module | Description | Data Scale Descriptors | Data Collection Frequency |
|---|---|---|---|---|
| H1_1 | H1 (Low back pain)_NASS Pain and Disability | 1a. In the past week, how often have you suffered low back and/or buttock pain? | 0= None of the time; 1= A little of the time; 2= Some of the time; 3= A good bit of the time; 4= Most of the time; 5= All of the time; | Baseline, every 3 months |
| H1_2 | H1 (Low back pain)_NASS Pain and Disability | 1b. How bothersome has the low back and/or buttock pain been? | 0= Not at all bothersome; 1= Slightly bothersome; 2= Somewhat bothersome; 3= Moderately bothersome; 4= Very bothersome; 5= Extremely bothersome | Baseline, every 3 months |
| H1_3 | H1 (Low back pain)_NASS Neuro | 2a. In the past week, how often have you suffered leg pain? | 0= None of the time; 1= A little of the time; 2= Some of the time; 3= A good bit of the time; 4= Most of the time; 5= All of the time; | Baseline, every 3 months |
| H1_4 | H1 (Low back pain)_NASS Neuro | 2b. How bothersome has the leg pain been? | 0= Not at all bothersome; 1= Slightly bothersome; 2= Somewhat bothersome; 3= Moderately bothersome; 4= Very bothersome; 5= Extremely bothersome | Baseline, every 3 months |
| H1_5 | H1 (Low back pain)_NASS Neuro | 3a. In the past week, how often have you suffered numbness or tingling in leg and/or foot? | 0= None of the time; 1= A little of the time; 2= Some of the time; 3= A good bit of the time; 4= Most of the time; 5= All of the time; | Baseline, every 3 months |
| H1_6 | H1 (Low back pain)_NASS Neuro | 3b. How bothersome has the numbness or tingling in leg and/or foot been? | 0= Not at all bothersome; 1= Slightly bothersome; 2= Somewhat bothersome; 3= Moderately bothersome; 4= Very bothersome; 5= Extremely bothersome | Baseline, every 3 months |
| H1_7 | H1 (Low back pain)_NASS Neuro | 4a. In the past week, how often have you suffered weakness in leg and/or foot? | 0= None of the time; 1= A little of the time; 2= Some of the time; 3= A good bit of the time; 4= Most of the time; 5= All of the time; | Baseline, every 3 months |
| H1_8 | H1 (Low back pain)_NASS Neuro | 4b. How bothersome has the weakness in leg and/or foot been? | 0= Not at all bothersome; 1= Slightly bothersome; 2= Somewhat bothersome; 3= Moderately bothersome; 4= Very bothersome; 5= Extremely bothersome | Baseline, every 3 months |
| H1_9 | H1 (Low back pain)_NASS Pain and Disability | 5. In the past week, how has pain affected you when you get dressed? | 0= I can dress myself without pain.; 1= I can dress myself without increasing pain.; 2= I can dress myself but pain increases.; 3= I can dress myself but with significant pain.; 4= I can dress myself but with very severe pain.; 5= I cannot dress myself due to pain.; | Baseline, every 3 months |
| H1_10 | H1 (Low back pain)_NASS Pain and Disability | 6. In the past week, how has pain affected you when you lift something? | 0= I can lift heavy objects without pain.; 1= I can lift heavy objects but it is painful.; 2= Pain prevents me from lifting heavy objects off the floor, but I can lift heavy objects if they are on a table.; 3= Pain prevents me from lifting heavy objects off the floor, but I can lift light to medium objects if they are on a table.; 4= I can only lift light objects due to pain.; 5= I cannot lift anything due to pain. | Baseline, every 3 months |
| H1_11 | H1 (Low back pain)_NASS Pain and Disability | 7. In the past week, how has pain affected you when you are walking and running? | 0= I can walk or run without pain.; 1= I can walk comfortably, but running is painful.;2= Pain prevents me from walking more than 1 hour.; 3= Pain prevents me from walking more than 30 minutes.;4= Pain prevents me from walking more than 10 minutes.; 5= I am unable to walk or can walk only a few steps at a time.; | Baseline, every 3 months |
| H1_12 | H1 (Low back pain)_NASS Pain and Disability | 8. In the past week, how has pain affected you when you are sitting? | 0= I can sit in any chair as long as I like.; 1= I can only sit in a special chair for as long as I like.; 2= Pain prevents me from sitting more than 1 hour.; 3= Pain prevents me from sitting more than 30 minutes.; 4= Pain prevents me from sitting more than 10 minutes.; 5= Pain prevents me from sitting at all.; | Baseline, every 3 months |
| H1_13 | H1 (Low back pain)_NASS Pain and Disability | 9. In the past week, how has pain affected you when you are standing? | 0= I can stand as long as I want.; 1= I can stand as long as I want but it gives me pain.; 2= Pain prevents me from standing more than 1 hour.; 3= Pain prevents me from standing more than 30 minutes.; 4= Pain prevents me from standing more than 10 minutes.; 5= Pain prevents me from standing at all.; | Baseline, every 3 months |
| H1_14 | H1 (Low back pain)_NASS Pain and Disability | 10. In the past week, how has pain affected you when you sleep? | 0= I sleep well.; 1= Pain occasionally interrupts my sleep.; 2= Pain interrupts my sleep half of the time.; 3= Pain often interrupts my sleep.; 4= Pain always interrupts my sleep.; 5= I never sleep well.; | Baseline, every 3 months |
| H1_15 | H1 (Low back pain)_NASS Pain and Disability | 11. In the past week, how has pain affected your social and recreational life? | 0= My social and recreational life is unchanged.; 1= My social and recreational life is unchanged, but it increases pain.; 2= My social and recreational life is unchanged, but it severely increases pain.; 3= Pain has restricted my social and recreational life.; 4= Pain has severely restricted my social and recreational life.; 5= I have essentially no social and recreational life because of pain.; | Baseline, every 3 months |
| H1_16 | H1 (Low back pain)_NASS Pain and Disability | 12. In the past week, how has pain affected your traveling? | 0= I can travel anywhere.; 1= I can travel anywhere but it gives me pain.; 2= Pain is bad but I can manage to travel over 2 hours.; 3= Pain restricts me to trip of less than 1 hour.; 4= Pain restricts me to trip of less than 30 minutes.; 5= Pain prevents me from traveling.; | Baseline, every 3 months |
| H1_17 | H1 (Low back pain)_NASS Pain and Disability | 13. In the past week, how has pain affected your sex life? | 0= My sex life is unchanged.; 1= My sex life is unchanged, but causes some pain.; 2= My sex life is nearly unchanged, but it is very painful.; 3= My sex life is severely restricted by pain.; 4= My sex life is nearly absent because of pain.; 5= Pain prevents any sex life at all.; | Baseline, every 3 months |
| H2_18 | H2 (DASH)_ DASH disability score (derived) | 1. Open a tight or new jar (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_19 | H2 (DASH)_ DASH disability score (derived) | 2. Do heavy household chores (e.g. wash walls, floors). (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_20 | H2 (DASH)_ DASH disability score (derived) | 3. Carry a shopping bag or briefcase. (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_21 | H2 (DASH)_ DASH disability score (derived) | 4. Wash your back. (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_22 | H2 (DASH)_ DASH disability score (derived) | 5. Use a knife to cut food. (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_23 | H2 (DASH)_ DASH disability score (derived) | 6. Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.). (Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_24 | H2 (DASH)_ DASH disability score (derived) | 7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours, or groups? | 1= not at all; 2= slightly; 3= moderately; 4= quite a bit; 5= extremely; | Baseline, every 3 months |
| H2_25 | H2 (DASH)_ DASH disability score (derived) | 8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem? | 1= not limited at all; 2= slightly limited; 3= moderately limited; 4= very limited; 5= unable; | Baseline, every 3 months |
| H2_26 | H2 (DASH)_ DASH disability score (derived) | 9. Arm, shoulder or hand pain. [Please rate the severity of the following symptoms in the last week (circle number).] | 1= none; 2= mild; 3= moderate; 4= severe; 5= extreme; | Baseline, every 3 months |
| H2_27 | H2 (DASH)_ DASH disability score (derived) | 10. Tingling (pins and needles) in your arm, shoulder or hand. [Please rate the severity of the following symptoms in the last week (circle number).] | 1= none; 2= mild; 3= moderate; 4= severe; 5= extreme; | Baseline, every 3 months |
| H2_28 | H2 (DASH)_ DASH disability score (derived) | 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= so much difficulty that I can’t sleep; | Baseline, every 3 months |
| H2_30 | H2 (DASH) Work Module | 1. Using your usual technique for your work? (Please circle the number that best describes your physical ability in the past week. Do you have any difficulty:) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_31 | H2 (DASH) Work Module | 2. Doing your usual work because of amr, shoulder or arm pain?(Please circle the number that best describes your physical ability in the past week. Do you have any difficulty:) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_32 | H2 (DASH) Work Module | 3. Doing your work as well as you would like? (Please circle the number that best describes your physical ability in the past week. Do you have any difficulty:) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H2_33 | H2 (DASH) Work Module | 4. Spending your usual amount of time doing your work? (Please circle the number that best describes your physical ability in the past week. Do you have any difficulty:) | 1= no difficulty; 2= mild difficulty; 3= moderate difficulty; 4= severe difficulty; 5= unable; | Baseline, every 3 months |
| H3_34 | H3 Job Tasks and Safety PART A | 1: Handling objects or stacked loads over 100 lbs. If never, please go to question 2 (such as appliances, large electronics equipment)? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_35 | H3 Job Tasks and Safety PART A | 1a. How often was the new Safety Grant equipment used to handle objects over 100 lbs.? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); 4= Not applicable (Safety Grant equipment not in place yet); | Baseline, every 3 months |
| H3_36 | H3 Job Tasks and Safety PART A | 1b. How often was another tool (such as regular hand truck) used to handle objects over 100 lbs.? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_37 | H3 Job Tasks and Safety PART A | 1c. How often did you use your body strength alone to handle large items? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_38 | H3 Job Tasks and Safety PART A | 2: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)?if never, please go to question 3 (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_39 | H3 Job Tasks and Safety PART A | 2a. How often was the new Safety Grant equipment used to handle objects 50–100 lbs.? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); 4= Not applicable (Safety Grant equipment not in place yet); | Baseline, every 3 months |
| H3_40 | H3 Job Tasks and Safety PART A | 2b. How often was another tool (such as regular hand truck) used to handle objects 50–100 lbs.? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_41 | H3 Job Tasks and Safety PART A | 2c. How often did you use your body strength alone to handle objects 50–100 lbs.? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_42 | H3 Job Tasks and Safety PART A | 3: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_43 | H3 Job Tasks and Safety PART A | 4: Packing/ unpacking boxes or containers (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_44 | H3 Job Tasks and Safety PART A | 5: Performing seated office work- computer use (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_45 | H3 Job Tasks and Safety PART A | 6. Performing standing office work- sales or customer service (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_46 | H3 Job Tasks and Safety PART A | 7: Driving a vehicle for work (PART A: Please rate how often on average you performed the following tasks in your daily work over the last 3 months.) | 0= Never (0% of the time); 1= Occasional (133% of the time); 2= Frequent (34–66% of the time); 3= Regular (67–100% of the time); | Baseline, every 3 months |
| H3_47 | H3 Job Tasks and Safety PART B | Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task. (Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_48 | H3 Job Tasks and Safety PART B | 1a: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_49 | H3 Job Tasks and Safety PART B | 1b: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_50 | H3 Job Tasks and Safety PART B | 1c: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_51 | H3 Job Tasks and Safety PART B | 1d: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_52 | H3 Job Tasks and Safety PART B | 1e: Handling objects or stacked loads over 100 lbs. (such as appliances, large electronics equipment)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_53 | H3 Job Tasks and Safety PART B | 2a: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_54 | H3 Job Tasks and Safety PART B | 2b: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_55 | H3 Job Tasks and Safety PART B | 2c: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_56 | H3 Job Tasks and Safety PART B | 2d: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_57 | H3 Job Tasks and Safety PART B | 2e: Handling objects or stacked loads 50–100 lbs. (such as large boxes, shipping containers)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_58 | H3 Job Tasks and Safety PART B | 3a: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_59 | H3 Job Tasks and Safety PART B | 3b: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_60 | H3 Job Tasks and Safety PART B | 3c: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_61 | H3 Job Tasks and Safety PART B | 3d: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_62 | H3 Job Tasks and Safety PART B | 3e: Handling objects or stacked loads 25–50 lbs. (such as boxes, parts)? (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_63 | H3 Job Tasks and Safety PART B | 4a: Packing/ unpacking boxes or containers (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_64 | H3 Job Tasks and Safety PART B | 4b: Packing/ unpacking boxes or containers (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_65 | H3 Job Tasks and Safety PART B | 4c: Packing/ unpacking boxes or containers (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_66 | H3 Job Tasks and Safety PART B | 4d: Packing/ unpacking boxes or containers (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_67 | H3 Job Tasks and Safety PART B | 4e: Packing/ unpacking boxes or containers (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_68 | H3 Job Tasks and Safety PART B | 5a: Performing seated office work- computer use (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_69 | H3 Job Tasks and Safety PART B | 5b: Performing seated office work- computer use (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_70 | H3 Job Tasks and Safety PART B | 5c: Performing seated office work- computer use (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_71 | H3 Job Tasks and Safety PART B | 5d: Performing seated office work- computer use (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_72 | H3 Job Tasks and Safety PART B | 5e: Performing seated office work- computer use (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_73 | H3 Job Tasks and Safety PART B | 6a. Performing standing office work- sales or customer service (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_74 | H3 Job Tasks and Safety PART B | 6b. Performing standing office work- sales or customer service (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_75 | H3 Job Tasks and Safety PART B | 6c. Performing standing office work- sales or customer service (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_76 | H3 Job Tasks and Safety PART B | 6d. Performing standing office work- sales or customer service (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_77 | H3 Job Tasks and Safety PART B | 6e. Performing standing office work- sales or customer service (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H3_78 | H3 Job Tasks and Safety PART B | 7a: Driving a vehicle for work (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) (Task Screening) | 0= no; 1= yes; | Baseline, every 3 months |
| H3_79 | H3 Job Tasks and Safety PART B | 7b: Driving a vehicle for work (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Slip, trip or fall | 0= no; 1= yes; | Baseline, every 3 months |
| H3_80 | H3 Job Tasks and Safety PART B | 7c: Driving a vehicle for work (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Cuts or scratches | 0= no; 1= yes; | Baseline, every 3 months |
| H3_81 | H3 Job Tasks and Safety PART B | 7d: Driving a vehicle for work (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Strains or sprains | 0= no; 1= yes; | Baseline, every 3 months |
| H3_82 | H3 Job Tasks and Safety PART B | 7e: Driving a vehicle for work (PART B: Have you had any safety related incidents at work within the last 3 months? If yes, please mark below which type of incident occurred for each type of task.) Other | 0= no; 1= yes; | Baseline, every 3 months |
| H4_83 | H4 General Health; SECTION A. GENERAL INFORMATION | 1: Age in years | age in years | Baseline, 1st and 2nd annual |
| H4_84 | H4 General Health; SECTION A. GENERAL INFORMATION | 2. Gender: (Male/ Female) | M= male; F = female; | Baseline, 1st and 2nd annual |
| H4_85 | H4 General Health; SECTION A. GENERAL INFORMATION | 3a. Your Height: FEET ____ | FEET ____ | Baseline, 1st and 2nd annual |
| H4_86 | H4 General Health; SECTION A. GENERAL INFORMATION | 3a. Your Height: INCHES_____ | INCHES_____ | Baseline, 1st and 2nd annual |
| H4_87 | H4 General Health; SECTION A. GENERAL INFORMATION | 4. Your Weight: POUNDS_____ | POUNDS_____ | Baseline, 1st and 2nd annual |
| H4_88 | H4 General Health; SECTION A. GENERAL INFORMATION | 5. In the past year, on average, how much total time did you spend in a vehicle each day? | 0= Less than 1 hour per day; 1= 1 hour to less than 2 hours per day; 2= 2 hours to less than 3 hours per day; 3= 3 hours to less than 5 hours per day; 4= More than 5 hours per day; | Baseline, 1st and 2nd annual |
| H4_89 | H4 General Health; SECTION B. WORK INFORMATION | 6. How long have you worked at this company? | 0= Less than 3 months; 1= 3 months to less than 1 year; 2= 1 year to less than 3 years; 3= 3 years to less than 5 years; 4= 5 years to less than 10 years; 5= 10 years or more; | Baseline, 1st and 2nd annual |
| H4_90 | H4 General Health; SECTION B. WORK INFORMATION | 7. How long have you worked in your current job? | 0= Less than 3 months; 1= 3 months to less than 1 year; 2= 1 year to less than 3 years; 3= 3 years to less than 5 years; 4= 5 years to less than 10 years; 5= 10 years or more; | Baseline, 1st and 2nd annual |
| H4_91 | H4 General Health; SECTION B. WORK INFORMATION | 8. On your job at this company, do you usually work: | 0= Regular daytime shift (first shift); 1= Regular evening shift (second shift); 2= Regular night shift (third shift); | Baseline, 1st and 2nd annual |
| H4_92 | H4 General Health; SECTION B. WORK INFORMATION | 9a. Do you work overtime at this company? | 0= No; 1= Yes; | Baseline, 1st and 2nd annual |
| H4_93 | H4 General Health; SECTION B. WORK INFORMATION | If yes, 9b. How many overtime HOURS PER WEEK do you USUALLY work? | 0= Less than 5 hours per week; 1= 5 to 10 hours per week; 2= 11 to 20 hours per week; 3= More than 20 hours per week ; | Baseline, 1st and 2nd annual |
| H4_94 | H4 General Health; SECTION B. WORK INFORMATION | 10a. Do you work at a second job (for a different employer)? | 0= No; 1= Yes; | Baseline, 1st and 2nd annual |
| H4_95 | H4 General Health; SECTION B. WORK INFORMATION | If yes, 10b. Does the second job involve LIFTING, PUSHING, PULLING, or CARRYING of MODERATE weight objects? | 0= No; 1= Sometimes; 2= Often; | Baseline, 1st and 2nd annual |
| H4_96 | H4 General Health; SECTION B. WORK INFORMATION | If yes, 10c. Does the second job involve LIFTING, PUSHING, PULLING, or CARRYING of HEAVY weight objects? | 0= No; 1= Sometimes; 2= Often; | Baseline, 1st and 2nd annual |
| H4_97 | H4 General Health; SECTION B. WORK INFORMATION | 10d. Does this second job involve bending your back at least as far forward as shown in the picture? | 0= Never or rarely; 1= Less than half of the time; 3= Half the time or more; | Baseline, 1st and 2nd annual |
| H4_98 | H4 General Health; SECTION C. PHYSICAL ACTIVITIES OUTSIDE OF WORK | 11. How many hours do you use your hands with moderate to heavy effort? (such as scrubbing, using a hammer, gripping a bowling ball, weight lifting, etc.): | 0= Less than 5 hours a week; 1= 5 to less than 10 hours a week; 2= 10 to less than 20 hours a week; 3= 20 or more hours a week; | Baseline, 1st and 2nd annual |
| H4_99 | H4 General Health; SECTION C. PHYSICAL ACTIVITIES OUTSIDE OF WORK | 12a. How many hours on average do you spend on activities in which you twist your back or bend forward at least as much as shown in this picture? (such as raking, working under the hood of a car, bathing a child, etc.) | 0= Less than 5 hours a week; 1= 5 to less than 10 hours a week; 2= 10 to less than 20 hours a week; 3= 20 or more hours a week; | Baseline, 1st and 2nd annual |
| H4_100 | H4 General Health; SECTION C. PHYSICAL ACTIVITIES OUTSIDE OF WORK | 12b. How many hours on average do you spend on activities in which you lift, push, pull or carry moderate to heavy weights? (such as children or groceries, moving furniture, shoveling, backpacking, etc.) | 0= Less than 5 hours a week; 1= 5 to less than 10 hours a week; 2= 10 to less than 20 hours a week; 3= 20 or more hours a week; | Baseline, 1st and 2nd annual |
| H4_101 | H4 General Health; SECTION D. HEALTH INFORMATION | 13. How would you rate your health compared to other persons your age? | 0= Poor; 1= Fair; 2= Good; 3= Very Good; 4= Excellent; | Baseline, 1st and 2nd annual |
| H4_102 | H4 General Health; SECTION E. NECK SYMPTOMS | 14. In the past 12 months, have you had NECK symptoms (pain, aching, stiffness, spasm, unable to move your head, burning, numbness or tingling) more than 3 times OR lasting a week (7 days) or longer? | 0= no; 1= yes; | Baseline, 1st and 2nd annual |
| H4_103 | H4 General Health; SECTION E. NECK SYMPTOMS | 15. In the past 12 months, how would you rate your level of NECK pain AT ITS WORST? | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_104 | H4 General Health; SECTION E. SHOULDER SYMPTOMS | 16. In the past 12 months, have you had SHOULDER symptoms (pain, aching, stiffness, spasm, unable to raise your arms, burning, numbness or tingling) more than 3 times OR lasting a week (7 days) or longer? | 0= no; 1= yes; | Baseline, 1st and 2nd annual |
| H4_105 | H4 General Health; SECTION E. SHOULDER SYMPTOMS | 17a. In the past 12 months, how would you rate your level of SHOULDER pain AT ITS WORST? LEFT shoulder: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_106 | H4 General Health; SECTION E. SHOULDER SYMPTOMS | 17b. In the past 12 months, how would you rate your level of SHOULDER pain AT ITS WORST? RIGHT shoulder: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_107 | H4 General Health; SECTION E. ELBOW/FOREARM SYMPTOMS | 18. In the past 12 months, have you had ELBOW/FOREARM symptoms (pain, aching, stiffness, burning, numbness or tingling) more than 3 times OR lasting a week (7 days) or longer? | 0= no; 1= yes; | Baseline, 1st and 2nd annual |
| H4_108 | H4 General Health; SECTION E. ELBOW/FOREARM SYMPTOMS | 19a. In the past 12 months, how would you rate your level of ELBOW/FOREARM pain AT ITS WORST? LEFT elbow/forearm: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_109 | H4 General Health; SECTION E. ELBOW/FOREARM SYMPTOMS | 19b. In the past 12 months, how would you rate your level of ELBOW/FOREARM pain AT ITS WORST? RIGHT elbow/forearm: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_110 | H4 General Health; SECTION E. HAND/WRIST SYMPTOMS | 20. In the past 12 months, have you had HAND/WRIST symptoms (pain, aching, stiffness, burning, numbness or tingling) more than 3 times OR lasting a week (7 days) or longer? | 0= no; 1= yes; | Baseline, 1st and 2nd annual |
| H4_111 | H4 General Health; SECTION E. HAND/WRIST SYMPTOMS | 21a. In the past 12 months, how would you rate your level of HAND/WRIST pain AT ITS WORST? LEFT hand/wrist: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_112 | H4 General Health; SECTION E. HAND/WRIST SYMPTOMS | 21b. In the past 12 months, how would you rate your level of HAND/WRIST pain AT ITS WORST? RIGHT hand/wrist: | 0= No pain; 1= Mild pain; 2= Moderate pain; 3= Severe pain; 4= Very severe pain; | Baseline, 1st and 2nd annual |
| H4_113 | H4 General Health; SECTION E. BACK SYMPTOMS | 22. In the past 12 months, have you had BACK pain every day for a week (7 days) or more? | 0= no; 1= yes; | Baseline, 1st and 2nd annual |
| H4_114 | H4 General Health; SECTION E. BACK SYMPTOMS | 23. a) In the past 12 months, ON AVERAGE, how intense was your back pain rated on a 0–10 scale where 0 is ‘no pain’ and 10 is ‘pain as bad as could be’? (That is, your usual pain at times you were experiencing pain.) | 0=0, 1=1; 2=2; 3=3; 4=4; 5=5; 6=6; 7=7; 8=8; 9=9; 10=10; | Baseline, 1st and 2nd annual |
| H4_115 | H4 General Health; SECTION E. BACK SYMPTOMS | 23 b) In the past 12 months, how intense was your WORST back pain rated on a 0–10 scale where 0 is ‘no pain’ and 10 is ‘pain as bad as could be’? | 0=0, 1=1; 2=2; 3=3; 4=4; 5=5; 6=6; 7=7; 8=8; 9=9; 10=10; | Baseline, 1st and 2nd annual |
| H4_116 | H4 General Health; SECTION E. BACK SYMPTOMS | 23c) How would you rate your back pain AT THE PRESENT TIME on a 0–10 scale, where 0 is “no pain” and 10 is “pain as bad as could be”? | 0=0, 1=1; 2=2; 3=3; 4=4; 5=5; 6=6; 7=7; 8=8; 9=9; 10=10; | Baseline, 1st and 2nd annual |