29 CFR 1910.1043 A Respiratory Questionnaire for Non-Textile Workers for th

APPENDIX B-II

Respiratory Questionnaire for Non-Textile Workers for the

Cotton Industry

__________________________________________________________________

Identification No. Interviewer Code

__________________________________________________________________

Location Date of Interview

__________________________________________________________________

1. IDENTIFICATION

__________________________________________________________________

1. NAME (Last) (First) (Middle Initial)

__________________________________________________________________

2. CURRENT ADDRESS (Number, Street, or Rural Route, City or Town,

County, State, Zip Code)

__________________________________________________________________

3. PHONE NUMBER AREA CODE NO.

( __ __ __ ) ___ ___ ___ - ___ ___ ___ ___

4. BIRTHDATE (Mo., Day, Yr.)

__________________________________________________________________

5. AGE LAST BIRTHDAY

__________________________________________________________________

6. SEX

1. ______ Male 2. ______ Female

7. ETHNIC GROUP OR ANCESTRY

1. ____ White, not of Hispanic Origin

2. ____ Black, not of Hispanic Origin

3. ____ Hispanic

4. ____ American Indian or Alaskan Native

5. ____ Asian or Pacific Islander

6. ____ Other: __________________________

8. STANDING HEIGHT

__________________ (cm)

9. WEIGHT

__________________

10. WORK SHIFT

1st ______ 2nd ______ 3rd ______

11. PRESENT WORK AREA

Please indicate primary assigned work area and percent of time spent at that site. If at other locations, please indicate and note percent of time for each.

PRIMARY WORK AREA
SPECIFIC JOB

12. APPROPRIATE INDUSTRY

1. _____ Garnetting

2. _____ Cottonseed Oil Mill

3. _____ Cotton Warehouse

4. _____ Utilization

5. _____ Cotton Classification

6. _____ Cotton Ginning

__________________________________________________________________

2. OCCUPATIONAL HISTORY TABLE

Complete the following table showing the entire work history of the individual from present to initial employment. Sporadic, part-time periods of employment, each of no significant duration, should be grouped if possible.

INDUSTRY AND LOCATION	TENURE OF EMPLOYMENT		SPECIFIC OCCUPATION	AVER-AGE NO. DAYS WORK-ED PER WEEK	HAZARDOUS HEALTH EXPOSURE ASSOCIATED WITH WORK
	FROM 19__ or 20 __	TO 19__ or 20 __			YES	NO	IF YES, DESCR-IBE

3. SYMPTOMS

Use actual wording of each question. Put X in appropriate square after each question. When in doubt record "No.".

COUGH

1. Do you usually cough first thing in the morning? (on getting up)* (Count a cough with first smoke or on "first going out of doors". Exclude clearing throat or a single cough.)

1._____Yes 2._____No

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

1. ____ Yes 2. ____ No

If YES to either 1 or 2:

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

1. ____ Yes 2. ____ No 3. ____ NA

4. Do you cough on any particular day of the week?

1. ____ Yes 2. _____ No

If YES:

5. Which day?

Mon. Tue. Wed. Thur. Fri. Sat. Sun. _____

PHLEGM

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

1. ____ Yes 2. ____ No

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

1. ____ Yes 2. ____ No

If YES to either question 6 or 7:

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

1. ____ Yes 2. ____ No

If YES to question 3 or 8:

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

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

* These words are for subjects who work at night.

CHEST ILLNESS

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

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

For subjects who usually have phlegm:

11. 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?)

1. ____ Yes 2. ____ No

If YES to 11:

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

1. ____ Yes 2. ____ No

13. Only one such illness with increased phlegm?

1. ____ Yes 2. ____ No

If YES to 12: During the past three years have you had:

14. More than one such illness:

1. ____ Yes 2. ____ No Br. Grade _____________

TIGHTNESS

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

1. ____ Yes 2. ____ No

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

1. ____ Yes 2. ____ No

17. If `Yes': Which day?

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

18. If YES Monday: At what time on Monday does your chest feel tight or your breathing difficult?

_____ Before entering mill _____ After entering mill

(ASK ONLY IF NO TO QUESTION 15)

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

1. ____ Yes 2. ____ No

20. If `Yes': Which day?

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

BREATHLESSNESS

21. If disabled from walking by any condition other than heart or lung disease put "X" in the space and leave questions (22-30) unasked.

________

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

1. ____ Yes 2. ____ No

If NO, grade is 1. If YES, proceed to next question.

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

1. ____ Yes 2. ____ No

If NO, grade is 2. If YES, proceed to next question.

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

1. ____ Yes 2. ____ No

If NO, grade is 3. If YES, proceed to next question.

25. Are you short of breath on washing or dressing?

1. ____ Yes 2. ____ No

If NO, grade is 4, If YES, grade is 5.

26.

Dyspnea Grd. __________________

ON MONDAYS:

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

1. ____ Yes 2. ____ No

If NO, grade is 1, If YES, proceed to next question.

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

1. ____ Yes 2. ____ No

If NO, grade is 2, If YES, proceed to next question.

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

1. ____ Yes 2. ____ No

If NO, grade is 3, If YES, proceed to next question.

30. Are you short of breath on washing or dressing?

1. ____ Yes 2. ____ No

If NO, grade is 4, If YES, grade is 5.

B. Grd. ___________________

OTHER ILLNESSES AND ALLERGY HISTORY

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

1. ____ Yes 2. ____ No

33. Have you ever had asthma?

1. ____ Yes 2. ____ No

If yes, did it begin:

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

34. If yes before 30: did you have asthma before ever going to work in a textile mill?

1. ____ Yes 2. ____ No

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

1. ____ Yes 2. ____ No

TOBACCO SMOKING

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

1. ____ Yes 2. ____ No

If NO to (33).

37. 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.)

1. ____ Yes 2. ____ No

If YES to (33) or (34); what have you smoked 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

(38)

Pipe

(39)

Cigars

(40)

41. If cigarettes, how many packs per day? Write in number of cigarettes	_____________________
	_____ Less than 1/2 pack _____ 1/2 pack, but less than 1 pack _____ 1 pack, but less than 1 1/2 packs _____ 1-1/2 packs or more
42. Number of pack years:	______________
43. If an ex-smoker (Cigarettes, cigar or pipe), how long since you stopped? (Write in number of years.)	______________
	_____ 0-1 year _____ 1-4 years _____ 5-9 years _____ 10+ years
OCCUPATIONAL HISTORY
Have you ever worked in:
44. A foundry? (As long as one year)	1. ____ Yes 2. ____ No
45. Stone or mineral mining, quarrying or processing? (As long as one year)	1. ____ Yes 2. ____ No
46. Asbestos milling or processing? (Ever)	1. ____ Yes 2. ____ No
47. Cotton or cotton blend mill? (For controls only)	1. ____ Yes 2. ____ No
48. Other dusts, fumes or smoke? If yes, specify.	1. ____ Yes 2. ____ No
Type of exposure ______________________ Length of exposure ______________________