Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx

Self-Escape Confidence Survey
The  purpose  of  these  questions  is  to  determine  your  level  of  confidence  in  your knowledge, skills and abilities related to escape from a mine during an emergency.
•	Mark your answers directly on the answer sheet with blue or black ink or pencil by circling your response or checking the box that corresponds with your answer.
•	Return your survey to us when you are done.

To protect your identity:
•	Your management will not see your individual responses.
•	Completed forms will not be made available to any management personnel.
•	We will combine the data from everyone into one large group to describe the results.

First, we’d like to get some general information about you and your experiences.

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxxx-xxxx).

Age:	18-24	25–34	35–44	45–54	55–64	65–74	75 +	
Are you:	Male	Female	
Are you?	Salary	Hourly	   Contractor	
Time in current job:	0–3 mos.	3–6 mos.	6–12	1-5 yrs.	6-10 yrs.	11-15 yrs.	16-20 yrs.	20+
mos.	yrs.	
Time in mine industry:	0–3 mos.	3–6 mos.	6–12	1-5 yrs.	6-10 yrs.	11-15 yrs.	16-20 yrs.	20+
mos.	yrs.	
Time with current mine:	0–3 mos.	3–6 mos.	6–12	1-5 yrs.	6-10 yrs.	11-15 yrs.	16-20 yrs.	20+
mos.	yrs.	
Work group:	Production	Maintenance	Safety         Engineer         Other _____________________	
General work schedule:	Set (start at the same time every day)	Varies (start at different times throughout the
week)	
Family mining history:	
First generation mineworker	Multi-generation mineworker
(e.g., parents/grandparents are/were mineworkers)	
Education level:	Less than high school    High school    Trade certificate    Associate’s        Bachelor’s          Master’s                                           
                                                                                                          degree            degree           degree or higher		

In general, what percentage (%) of your time at work is spent underground?	N/A	0	10	20	30	40	50	60	70	80	90	100	

Do you have training or experience with any of the following? (Check all that apply)
•	Volunteer fire fighting
•	Professional fire fighting
•	Military emergency response
•	EMT/Paramedic
•	Mine fire brigade
•	Mine rescue team
•	Evacuating a mine due to a mine emergency
•	Other emergency response related training/experience: ______________________________

Do you currently hold any of the following positions? (Check all that apply)
•	Responsible Person
•	Shift supervisor
•	Section supervisor
•	Other supervisory/leadership role:
____________________________________

Please rate your confidence in the following areas, from “0” (Completely Unconfident) to “100” (Completely Confident) by checking the number below each statement.

How confident are you that you could correctly demonstrate or explain the following to a new miner?	% confident	
1.   Your mine’s emergency response plan (ERP)	N/A	0	10	20	30	40	50	60	70	80	90	100	
2.   The chain of command for reporting a mine emergency	N/A	0	10	20	30	40	50	60	70	80	90	100	0	10	20	30	40	50	60	70	80	90	100	
3.    The location of your mine’s primary and secondary escapeways	N/A	0	10	20	30	40	50	60	70	80	90	100	
4.   Where your mine’s escapeway maps are located	N/A	0	10	20	30	40	50	60	70	80	90	100	
5.   Where to report in the event of a mine emergency	N/A	0	10	20	30	40	50	60	70	80	90	100	
6.   Mine map symbols	N/A	0	10	20	30	40	50	60	70	80	90	100	
7.   Where your mine’s escape routes are located	N/A	0	10	20	30	40	50	60	70	80	90	100	
8.   Lifeline symbols	N/A	0	10	20	30	40	50	60	70	80	90	100	
9.   If or when to fight a fire	N/A	0	10	20	30	40	50	60	70	80	90	100	
10.   How to use a fire extinguisher	N/A	0	10	20	30	40	50	60	70	80	90	100	
11. How to identify an explosive atmosphere with a gas meter	N/A	0	10	20	30	40	50	60	70	80	90	100	
12. The dangers of carbon monoxide (CO)	N/A	0	10	20	30	40	50	60	70	80	90	100	
13. Where your mine’s SCSR caches are located	N/A	0	10	20	30	40	50	60	70	80	90	100	
14. When to don a SCSR	N/A	0	10	20	30	40	50	60	70	80	90	100	
15. How to properly don a SCSR	N/A	0	10	20	30	40	50	60	70	80	90	100	
16. What to expect when wearing a SCSR (e.g., how will it feel to breathe, communicate, etc.)	N/A	0	10	20	30	40	50	60	70	80	90	100	
17. Roof testing	N/A	0	10	20	30	40	50	60	70	80	90	100	
18. Setting roof supports	N/A	0	10	20	30	40	50	60	70	80	90	100	
19. Ventilation/smoke leakage	N/A	0	10	20	30	40	50	60	70	80	90	100	
20. Reestablishing ventilation	N/A	0	10	20	30	40	50	60	70	80	90	100	
21. Where your mine’s refuge alternative(s) (RA) is/are located	N/A	0	10	20	30	40	50	60	70	80	90	100	
22. When to enter your mine’s refuge alternative (RA)	N/A	0	10	20	30	40	50	60	70	80	90	100	
23. How to operate your mine’s refuge alternative (RA)	N/A	0	10	20	30	40	50	60	70	80	90	100	
24. When to construct a barricade	N/A	0	10	20	30	40	50	60	70	80	90	100	
25. How to construct a proper barricade	N/A	0	10	20	30	40	50	60	70	80	90	100	
26. Your mine’s communication and tracking (CT) system	N/A	0	10	20	30	40	50	60	70	80	90	100	
27. Your mine’s atmospheric monitoring system (AMS)	N/A	0	10	20	30	40	50	60	70	80	90	100