Confidential Survey

Participation in this survey is voluntary. Unless you want to release your contact information at the end of the survey so we can get in touch with you, your identity and responses are anonymous. Thank you for participating.

Making TSCA Matter for Workers is a joint project of the American Public Health Association Occupational Health and Safety Section, United Steelworkers (USW), Asbestos Disease Awareness Organization, BlueGreen Alliance, Earthjustice, and the National Council for Occupational Safety and Health (NCOSH).

Question Title

* 1. What is your age?

Question Title

* 2. What is your gender?

Female

Male

3. From the following list of chemicals, please select each chemical that you currently use or have previously used in your workplace.

Question Title

* 3a. Chemicals for degreasing, paint stripping, glues, paints, cleaners:

Trichloroethylene

Tetrachloroethylene

1-Bromopropane

Carbon Tetrachloride

Methylene Chloride

1,4-Dioxane

N-Methyl-2-pyrrolidone

Don't know. I've used chemical products, but I don't know if they contained any of these chemicals.

Question Title

* 3b. Colorant:

Pigment Violet 29

Question Title

* 3c. Flame retardant:

HBCD

Question Title

* 3d. Asbestos

Building maintenance, renovation, or demolition

Disaster clean-up

Repairing automotive brakes or clutches

Manufacturing chlorine

If your answer is "none" please stop here. Please provide your contact information at the end of the survey if you would like us to contact you with further information.

If you selected one or more chemicals, please choose one chemical that you're most concerned about and fill out the rest of the survey based on that one chemical. You can complete the survey more than one time if you've been exposed to more than one of these chemicals.