California ED Work-Related Asthma Survey Question Title * 1. Consent Form:The California Department of Public Health Work-related Asthma Prevention Program is working on a project to identify and prevent work-related job hazards that cause various lung conditions. We learned of your lung condition from a report that your hospital was required to complete for all emergency department visits. This report was sent to the State. The report was about your emergency department visit(s) for asthma in 2016. The health department is trying to learn more about how exposures to chemicals in the workplace can cause lung problems. Your experience can help us understand the causes of work-related lung disease and help us take steps to prevent it from happening to others. Information about your experience can help us make policy recommendations that will create safer and healthier working conditions.If you would be willing to complete a 1-2 minute questionnaire, you will be asked the 6 quick multiple choice follow-up questions below about your lung condition and your work, including possible exposures to chemicals. Any answers you give will be strictly confidential. It is important you answer the questions even if you don't know if your lung condition is related to your work. We do not anticipate any risks to you from completing the questionnaire. Your participation with this questionnaire is entirely voluntary; you can skip any questions you don't want to answer, and you can leave the questionnaire at any point. If you like, we will send you some information about occupational asthma and how it can be prevented on the job. If you have any questions or concerns about this questionnaire or project, please don't hesitate to call our staff doctor, Dr. Robert Harrison, at (510) 620-5769 or Jennifer Flattery, project manager, at 510-620-5765.Checking the "Agree" box below indicates that you have read the above information and voluntarily agree to participate.If you do not wish to complete this questionnaire, please decline participation by checking the "Disagree" box below. Agree Disagree OK Question Title * 2. Please type your unique User ID, exactly as it is shown in the CDPH letter that you received. OK Question Title * 3. Was your emergency department visit mentioned in the CDPH letter for asthma related to your work or made worse by your work? Yes No OK Question Title * 4. Have you ever before sought medical care for asthma related to work conditions or exposures? Yes No OK Question Title * 5. Was your asthma caused or made worse by things like chemicals, smoke, dust, or mold in any job you've ever had? Yes No OK Question Title * 6. Which of the following best describes you at the time of your ED visit? Employed for wages Self-employed Out of work for 1 year or more Out of work for less than 1 year Homemaker Student Retired Unable to work OK Question Title * 7. Would you like to receive educational materials about work-related asthma? Yes No OK DONE