Appendix 2: Health Survey SURVEY OF OCCUPATIONAL EXPOSURES AND HEALTH STATUS ID Number: Employer: Workplace: Exposed to Fumigants: Yes No Number of workers employed: Name: Today’s date: Date of Birth (DD/MM/YY): Sex: Male Female YOUR CURRENT WORK 1. How many years have you worked in your current job? Years 2. How many hours per week do you work in this job (on average)? Hours per week 3. What is the main activity of the company you work for? For example, what is produced, what service is produced? 4. Please describe your specific job in detail: 5. In addition to your current job, do you have another job at present? No Yes—Please specify GENERAL HEALTH QUESTIONS
HOW OFTEN HAVE YOU DURING RECENT MONTHS EXPERIENCED ANY OF THE FOLLOWING AND FOR HOW MANY YEARS HAVE YOU HAD THESE SYMPTOMS? 1 – Seldom or never 2 – 3 – Often 4 – Very often Number of years experienced 14. Dropping things unintentionally 1 2 3 4 15. Weakness of your arms and feet 1 2 3 4 16. Decreased sensation in arms and legs 1 2 3 4 17. Numbness or heaviness in your arms or legs 1 2 3 4 18. Tingling in your arms or legs 1 2 3 4 19. Problems with balance 1 2 3 4 20. Changes in sense of smell or taste 1 2 3 4 21. Decreased sensation on your face 1 2 3 4 22. Difficulties controlling your hand movements (i.e. how often do you notice your hands are more clumsy?) 1 2 3 4 23. Slowness in carrying out your daily activities 1 2 3 4 24. Trembling of hands 1 2 3 4 25. Headache 1 2 3 4 26. Sweating for no obvious reason 1 2 3 4 27. Nausea (i.e. do you feel sick in your stomach?) 1 2 3 4 1 – Seldom or never 2 – 3 – Often 4 – Very often Number of years experienced 28. Stomach pains 1 2 3 4 29. Dizziness 1 2 3 4 30. Shortness of breath without physical exertion 1 2 3 4 31. Heart fluttering (palpitations) 1 2 3 4
shipping containers? ALL workers need to answer this question. Please circle all that apply. I have no training for unpacking shipping containers 02 My supervisor/boss doesn’t enforce safety procedures (poor supervision) 03 My co-workers don’t follow safety procedures 04 I don’t think there is much risk to myself from exposure to chemical fumes 05 I am prepared to take the risk (it’s a lottery anyway) 06 I don’t think the safety procedures are very effective (not worth the effort) 07 I don’t have confidence in being able to take necessary safety precautions 08 The necessary safety equipment is not provided 09 Wearing the protective equipment is uncomfortable or makes the task more difficult 10 It takes too long to follow the safety procedures (too difficult, too complicated) 11 It is too expensive to do everything by the book 12 There is little chance of being detected by WHS Inspectors 13 Don’t know 14 Other SPECIFY 15 Q28 Which of these reasons is the most significant reason for not taking safety precautions? Please circle one response only. I am not aware that the shipping container may give off chemical fumes 01 I have no training for unpacking shipping containers 02 My supervisor/boss doesn’t enforce safety procedures (poor supervision) 03 My co-workers don’t follow safety procedures 04 I don’t think there is much risk to myself from exposure to chemical fumes 05 I am prepared to take the risk (it’s a lottery anyway) 06 I don’t think the safety procedures are very effective (not worth the effort) 07 I don’t have confidence in being able to take necessary safety precautions 08 The necessary safety equipment is not provided 09 Wearing the protective equipment is uncomfortable or makes the task more difficult 10 It takes too long to follow the safety procedures (too difficult, too complicated) 11 It is too expensive to do everything by the book 12 There is little chance of being detected by WHS Inspectors 13 Don’t know 14 Other SPECIFY 15 THANK YOU FOR YOUR PARTICIPATION