29 CFR 1910.1043 A Abbreviated Respiratory Questionnaire

APPENDIX B-III

ABBREVIATED 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 (synthetic & 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 (2) ____ More than 2 years-9 years (3) ____ 10-19 years (4) ____ 20+ years
* These words are for subjects who work at night
TIGHTNESS
Does your chest ever feel tight or your breathing become difficult?					Yes _______ No _______ (39)
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 _______ (40)
If `Yes': Which day? (3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (41) (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 (42) (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 _______ (43)
If `Yes': Which day? (3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (44) (1) / \ (2) Sometimes Always
TOBACCO SMOKING
* Have you changed your smoking habits since last interview? If yes, specify what changes.