Gov. Office Status
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services
www.hhs.gov

NIH Public Health Emergency and
Disaster Research Response (DR2)

National Institutes of Health National Institutes of
Environmental Health Sciences
U.S. National Library of Medicine
SearchClear Search TermsPrint/DownloadHelp
From Disaster Lit®, a database of the NLM Disaster Information Management Research Center.
Refine Your Results

From Disaster Lit®, a database of the NLM Disaster Information Management Research Center.
Print Page Download Records Return to Results
Skip to main content

Refine Your Results

Data Collection on

COVID-19 Main Topics

Publication Type

Source

REDCap


Results from:

Disaster Lit logo
View additional search results from Disaster Lit
PubMed logo
View search results from PubMed
MedlinePlus logo
View search results from MedlinePlus
Displaying records 1 - 3 of 3
      of 1      
  1. Exposure History Form
    Source: Agency for Toxic Substances and Disease Registry (ATSDR)
    Format: PDF
    Annotation: This form is from the Agency for Toxic Substances and Disease Registry (ATSDR). Past and current exposures are recorded on Part 1 of an Exposure History Form, which is designed for easy completion by the patient and a quick scan for pertinent details by the clinician. The questions investigate changes in routines and work site characteristics; details about known toxicant exposure; known exposure to metals, dust, fibers, fumes, chemicals, physical agents, and biologic hazards; other persons affected; protective equipment use; and temporal patterns and activities. Part 2 of the Exposure History Form is a comprehensive inventory of hazardous exposures in the patient's present and past occupations. Part 3 of the form examines environmental history to exposure(s). This resource was identified by the NIH Disaster Research Response Program (DR2) for researchers looking for pre- and post-disaster data collection instruments.

    Ease of Use in Disaster Setting: Moderate
    Flesch-Kincaid Reading Level: Grade 6.1
    Population: Multiple Groups
    Length: 38 questions; Part 2 of the survey (work history and list of possible exposures) is not numbered and is not included in the question count.
    Administered by: Self Administered/Self Report, Lay Interviewer, Specialist/Doctor/Expert
    Language(s): English    ...[See more] [See less]
    URL: https://www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf
    Type: Guideline/Assessment Tool
    Access Notes: Free/Publicly Available

    Citation(s):
    Goldman RH, Peters JM. The occupational and environmental health history. JAMA. 1981 Dec 18;246(24):2831-6. PubMed PMID: 7310975.
    https://www.ncbi.nlm.nih.gov/pubmed/7310975. Subscription required.

    Obtaining an exposure history. Agency for Toxic Substances and Disease Registry. United States department of Health and Human Services, Public Health Service, Atlanta, Georgia. Am Fam Physician. 1993 Sep 1;48(3):483-91. PubMed PMID: 8362697.
    https://www.ncbi.nlm.nih.gov/pubmed/8362697. Subscription required.

    Marshall L, Weir E, Abelsohn A, Sanborn MD. Identifying and managing adverse environmental health effects: 1. Taking an exposure history. CMAJ. 2002 Apr 16;166(8):1049-55. Review. PubMed PMID: 12002983; PubMed Central PMCID: PMC100881
    https://www.ncbi.nlm.nih.gov/pubmed/12002983. Subscription not required.

    Contact information:
    Institution: Agency for Toxic Substances and Disease Registry
    Address: 4770 Buford Hwy NE
    Atlanta, GA 30341
    Phone: 800-CDC-INFO (800-232-4636)
    TTY: (888) 232-6348

    Download free, publicly available document as adapted for the NIH Disaster Research Response Program:

    Exposure History Form:
    Epi Info file (XML)
    Epi Info Instructions

    Includes Research Tools: Yes.
    ID: 7821. From: Disaster Lit®a database of the U.S. National Library of Medicine.
  2. ATSDR (Agency for Toxic Substances and Disease Registry) Rapid Response Registry Survey Form
    Source: Agency for Toxic Substances and Disease Registry (ATSDR)
    Format: Text
    Annotation: The Agency for Toxic Substances and Disease Registry Rapid Response Registry (ATSDR-RRR) survey instrument gives local, state, or federal entities a tool to register responders and other persons exposed to chemical, biological, or nuclear agents from a disaster. The survey instrument is a two-page form that can be distributed on paper or electronically. It can be implemented quickly to collect information to identify and locate victims and people displaced or affected by a disaster. This tool gathers information on the following areas: demographics (e.g., name, age, gender, home address, status, and place of employment), health information, exposure information, exposure-related health effects, immediate health/safety needs, and health insurance. This resource was identified by the NIH Disaster Research Response Program (DR2) for researchers looking for pre- and post-disaster data collection instruments.

    Ease of Use in Disaster Setting: Moderate
    Population: All/Anyone
    Length: 38 questions
    Time to Complete: Five minutes or less
    Administered by: Self Administered/Self Report, Lay Interviewer, Specialist/Doctor/Expert
    Language(s): English    ...[See more] [See less]
    URL: https://www.atsdr.cdc.gov/rapidresponse/
    Type: Guideline/Assessment Tool
    Access Notes: Free/Publicly Available

    Citation(s):
    Duncan MA, Orr MF. Evolving with the times, the new national toxic substance incidents program. J Med Toxicol. 2010 Dec;6(4):461-3. doi:10.1007/s13181-010-0114-6. PubMed PMID: 20838954; PubMed Central PMCID: PMC3550462. https://www.ncbi.nlm.nih.gov/pubmed/20838954. Subscription not required.

    Contact information:

    Institution: Agency for Toxic Substances and Disease Registry
    Address: 4770 Buford Highway NE, Atlanta, GA 30341
    Phone: 800-232-4636/TTY: 888-232-6348; 404-567-3256
    Web: https://www.atsdr.cdc.gov/rapidresponse/
    Direct link to document: https://www.atsdr.cdc.gov/rapidresponse/docs/RRRSurveyForm_V021706.doc

    Institution: Centers for Disease Control and Prevention Emergency Operations Center
    Phone: 770-488-7100; ask for the ACE team.
    Email: ATSDRACE@cdc.gov
    Includes Research Tools: Yes.
    ID: 8638. From: Disaster Lit®a database of the U.S. National Library of Medicine.
  3. Assessment of Chemical Exposures (ACE) General Survey
    Source: Agency for Toxic Substances and Disease Registry (ATSDR)
    Format: Text
    Annotation: The Assessment of Chemical Exposures (ACE) General Survey can be used in an interview with adults or children aged 13 and older. The survey assesses exposure, acute health effects, demographic information, medical history, occupational history, and communications. This resource was identified by the NIH Disaster Research Response Program (DR2) for researchers looking for pre- and post-disaster data collection instruments.

    Ease of Use in Disaster Setting: Difficult
    Population: All/Anyone
    Length: 72 questions, 14 sections; this does not include subsets of questions.
    Time to Complete: Not specified/given
    Administered by: Self Administered/Self Report, Lay Interviewer, Specialist/Doctor/Expert
    Language(s): English and Spanish    ...[See more] [See less]
    URL: https://www.atsdr.cdc.gov/ntsip/ace_toolkit.html
    Type: Guideline/Assessment Tool
    Access Notes: Free/Publicly Available

    Citation(s):
    Duncan MA, Orr MF. Evolving with the times, the new national toxic substance incidents program. J Med Toxicol. 2010 Dec;6(4):461-3. doi: 10.1007/s13181-010-0114-6. PubMed PMID: 20838954; PubMed Central PMCID: PMC3550462. https://www.ncbi.nlm.nih.gov/pubmed/20838954. Subscription not required.

    Contact information:

    Institution: Agency for Toxic Substances and Disease Registry
    Address: 4770 Buford Highway NE, Atlanta, GA 30341
    Phone: 800-232-4636; TTY: 888-232-6348; 404-567-3256

    Institution: Centers for Disease Control and Prevention (CDC) Emergency Operations Center
    Phone: 770-488-7100; ask for the ACE team.
    Email: ATSDRACE@cdc.gov
    Includes Research Tools: Yes.
    ID: 8639. From: Disaster Lit®a database of the U.S. National Library of Medicine.
      of 1