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 Years your current job? 2. How many hours per week do you Hours per week work in this job (on average)? 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 No have another job at present? Yes—Please specify GENERAL HEALTH QUESTIONS
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
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