Form 29 CFR 1910.1043 A 29 CFR 1910.1043 A Respiratory Questionnaire

APPENDIX B-I

RESPIRATORY QUESTIONNAIRE

1. IDENTIFICATION DATA

PLANT ______________________

DAY MONTH YEAR

(figures) (last 2 digits)

NAME ____________________ DATE OF INTERVIEW _______________________

(Surname)

______________________________ DATE OF BIRTH ________________________

(First Names)

M F

ADDRESS ____________________ AGE ____ (8, 9) SEX _____________(10)

W N IND OTHER

____________________________ RACE _____ _____ _____ _______ (11)

INTERVIEWER: 1 2 3 4 5 6 7 8 (12)

WORK SHIFT: 1st _____ 2nd _____ 3rd _____ (13)

STANDING HEIGHT __________________________ (14, 15)

WEIGHT _____________________________________ (16, 18)

PRESENT WORK AREA

If working in more than one specified work area, X area where most of the work shift is spent. If "other," but spending 25% of the work shift in one of the specified work areas, classify in that work area. If carding department employee, check area within that department where most of the work shift is spent (if in doubt, check "throughout"). For work areas such as spinning and weaving where many work rooms may be involved, be sure to check to specific work room to which the employee is assigned - if he works in more than one work room within a department classify as 7 (all) for that department.

	Work- room Number	(19) Open	(20) Pick	Area	(21) Card #1	(22) #2	(23) Spin	(24) Wind	(25) Twist
AT RISK (cotton & cotton blend)	1			Cards
	2			Draw
	3			Comb
	4			Thru Out
	5
	6
	7 (all)
Control (synthe-tic & wool)	8
Ex- Worker (cotton)	9

Continued –

	Work- Room Number	(26) Spool	(27) Warp	(28) Slash	(29) Weave	(30) Other
AT RISK (cotton & cotton blend)	1
	2
	3
	4
	5
	6
	7 (all)
Control (synthetic & wool)	8
Ex- Worker (cotton)	9

Use actual wording of each question. Put X in appropriate square after each question. When in doubt record “No”. When no square, circle appropriate answer.

COUGH (on getting up)

Do you usually cough first thing in the morning?

___________________________ Yes _______ No _______ (31)

(Count a cough with first smoke or on “first going out of doors.” Exclude clearing throat or a single cough.)

Do you usually cough during the day or at night? (Ignore an occasional cough.)

Yes _______ No _______ (32)

If `Yes' to either question (31-32):

Do you cough like this on most days for as much as three months a year?

Yes _______ No _______ (33)

Do you cough on any particular day of the week?

Yes _______ No _______ (34)

(1) (2) (3) (4) (5) (6) (7) If ‘Yes’: Which day? Mon Tues Wed Thur Fri Sat Sun (35) ­­­­­­­­­­­­­­___________________________________________________________________

PHLEGM or alternative word to suit local custom. (on getting up)

Do you usually bring up any phlegm from your chest first thing in the morning? (Count phlegm with the first smoke or on “first going out of doors.” Exclude phlegm from the nose. Count swallowed phlegm.)

Yes _______ No ______ (36)

Do you usually bring up any phlegm from your chest during the day or at night? (Accept twice or more.)

Yes _______ No ______ (37)

If `Yes' to question (36) or (37):

Do you bring up any phlegm like this on most days for as much as three months each year?

Yes _______ No ______ (38)

If `Yes' to question (33) or (38):

(cough) How long have you had this phlegm? (Write in number of years)

(1) ____ 2 years or less (39) (2) ____ More than 2 year-9 years (3) ____ 10-19 years (4) ____ 20+ years

* These words are for subjects who work at night

CHEST ILLNESSES

In the past three years, have you had a period of (increased) *cough and phlegm lasting for 3 weeks or more?

(1) ____ No (40) (2) ____ Yes, only one period (3) ____ Yes, two or more periods

*For subjects who usually have phlegm

During the past 3 years have you had any chest illness which has kept you off work, indoors at home or in bed? (For as long as one week, flu?)

Yes _______ No ______ (41)

If `Yes' to (41):

Did you bring up (more) phlegm than usual in any of these illnesses?

Yes _______ No ______ (42)

If `Yes' to (42):

During the past three years have you had:

Only one such illness with increased phlegm? (1) _____ (43) More than one such illness: (2) ______(44) Br. Grade _______

TIGHTNESS

Does your chest ever feel tight or your breathing become difficult?

Yes _______ No _______ (45)

Is your chest tight or your breathing difficult on any particular day of the week? (after a week or 10 days from the mill)

Yes _______ No _______ (46)

If `Yes': Which day? (3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (47) (1) / \ (2) Sometimes Always

If `Yes' Monday: At what time on Monday does your chest feel tight or your breathing difficult?

(1) ___ Before entering the mill (48) (2) ___ After entering the mill

(Ask only if NO to Question (45))

In the past, has your chest ever been tight or your breathing difficult on any particular day of the week?

Yes _______ No _______ (49)

If `Yes': Which day?

(3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (50) (1) / \ (2) Sometimes Always

BREATHLESSNESS

If disabled from walking by any condition other than heart or lung disease put "X" here and leave questions (52-60) unasked.

____________________(51)

Are you ever troubled by shortness of breath, when hurrying on the level or walking up a slight hill?

Yes ______ No ______ (52)

If `No', grade is 1.

If `Yes', proceed to next question.

Do you get short of breath walking with other people at an ordinary pace on the level?

Yes _______ No _______ (53)

If `No', grade is 2.

If `Yes', proceed to next question.

Do you have to stop for breath when walking at your own pace on the level?

Yes _______ No _______ (54)

If `No', grade is 3.

If `Yes', proceed to next question.

Are you short of breath on washing or dressing?

Yes _______ No _______ (55)

If `No', grade is 4. If `Yes' grade is 5.

Dyspnea Grd. __________ (56)

ON MONDAYS

Are you ever troubled by shortness of breath, when hurrying on the level or walking up a slight hill?

Yes _______ No _______ (57)

If `No', grade is 1.

If `Yes', proceed to next question.

Do you get short of breath walking with other people at ordinary pace on the level?

Yes _______ No _______ (58)

If `No', grade is 2.

If `Yes', proceed to next question.

Do you have to stop for breath when walking at your own pace on level ground?

Yes _______ No _______ (59)

If `No', grade is 3.

If `Yes', proceed to next question.

Are you short of breath on washing or dressing?

Yes _______ No _______ (60)

If `No', grade is 4. If `Yes', grade is 5.

B. Grd. _______________ (61)

OTHER ILLNESSES AND ALLERGY HISTORY

Do you have a heart condition for which you are under a doctor's care?

Yes _______ No ________ (62)

Have you ever had asthma?

Yes _______ No ________ (63)

If `Yes', did it begin:

(1) _______ Before age 30 (2) _______ After age 30

If `Yes' before 30 did you have asthma before ever going to work in a textile mill?

Yes _______ No ________ (64)

Have you ever had hay fever or other allergies (other than above)?

Yes _______ No ________ (65)

TOBACCO SMOKING*

Do you smoke? Record `Yes', if regular smoker up to one month ago (Cigarettes, cigar or pipe)

Yes _______ No _______ (66)

If `No' to (63)

Have you ever smoked? (Cigarettes, cigars, pipe. Record `No' if subject has never smoked as much as one cigarette a day, or 1 oz of tobacco a month, for as long as one year.)

Yes _______ No _______ (67)

If `Yes' to (63) or (64), what have you smoked and for how many years? (Write in specific number of years in the appropriate square)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

Years

<5

5-9

10-14

15-19

20-24

25-29

30-34

35-39

>40

Cigarettes

(68)

Pipe

(69)

Cigars

(70)

If cigarettes, how many packs per day? (Write in number of cigarettes)				(1) ______ Less than 1/2 pack (71) (2) ______ 1/2 pack, but less than 1 pack (3) ______ 1 pack, but less than 1 ½ packs (4) ______ 1 1/2 packs or more
Number of years				__________________________ (72, 73)
If an ex smoker (cigarettes, cigar or pipe), how long since you stopped? (Write in number of years)				__________________________ (74) (1) ______ 0-1 year (2) ______ 1-4 years (3) ______ 5-9 years (4) ______ 10+ years
* Have you changed your smoking habits since last interview? If yes, specify what changes.
OCCUPATIONAL HISTORY**
Have you ever worked in:
A foundry? (As long as one year)					Yes _______ No _______ (75)
Stone or mineral mining, quarry or processing? (As long as one year)					Yes _______ No _______ (76)
Asbestos milling or processing?					Yes _______ No _______ (77)
Other dusts, fumes or smoke? If yes, specify.					Yes _______ No _______ (78)
Type of exposure				__________________________________
Length of exposure				__________________________________
** Ask only on first interview.
At what age did you first go to work in a textile mill? (Write in specific age in appropriate square)
(1)	(2)	(3)	(4)			(5)	(6)
<20	20-24	25-29	30-34			35-39	40+

When you first worked in a textile mill, did you work with:

(1) ______ Cotton or cotton blend (79) (2) ______ Synthetic or wool (80)