- Part Number:1910
- Part Number Title:Occupational Safety and Health Standards
- Subpart:1910 Subpart Z
- Subpart Title:Toxic and Hazardous Substances
- Standard Number:
- Title:Respiratory Questionnaire
- GPO Source:
Appendix B-I
RESPIRATORY QUESTIONNAIRE
A. 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)
RACE (11) (Check all that apply)
1. White __ 4. Hispanic or Latino __
2. Black or African American __ 5. American Indian or Alaska Native __
3. Asian __ 6. Native Hawaiian or
Other Pacific Islander __
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- (19) (20) (21) (22) (23) (24) (25)
room Card
Number Open Pick Area #1 #2 Spin Wind Twist
_________________________________________________________________
| | | | | | | | | |
AT RISK | 1 | | |Cards| | | | | |
(cotton |_______|______|_____|_____|____|____|_____|_____|______|
& | | | | | | | | | |
cotton | | | | | | | | | |
blend) | 2 | | |Draw | | | | | |
|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
| 3 | | |Comb | | | | | |
|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
| 4 | | |Thru | | | | | |
| | | |Out | | | | | |
|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
| 5 | | | | | | | | |
| | | | | | | | | |
|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
| 6 | | | | | | | | |
|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
| 7 | | | | | | | | |
| (all) | | | | | | | | |
________|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
Control | | | | | | | | | |
(synthe-| 8 | | | | | | | | |
tic & | | | | | | | | | |
wool) | | | | | | | | | |
________|_______|______|_____|_____|____|____|_____|_____|______|
| | | | | | | | | |
Ex- | | | | | | | | | |
Worker | 9 | | | | | | | | |
(cotton)| | | | | | | | | |
| | | | | | | | | |
________|_______|______|_____|_____|____|____|_____|_____|______|
Continued --
Work- (26) (27) (28) (29) (30)
room
Number Spool Warp Slash Weave Other
________________________________________________
| | | | | | |
AT RISK | 1 | | | | | |
(cotton |_______|______|_____|_____|_____|_____|
& | 2 | | | | | |
cotton |_______|______|_____|_____|_____|_____|
blend) | | | | | | |
| 3 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 4 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 5 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 6 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 7 | | | | | |
| (all) | | | | | |
________|_______|______|_____|_____|_____|_____|
| | | | | | |
Control | | | | | | |
(synthe-| 8 | | | | | |
tic & | | | | | | |
wool) | | | | | | |
________|_______|______|_____|_____|_____|_____|
| | | | | | |
Ex- | | | | | | |
Worker | 9 | | | | | |
(cotton)| | | | | | |
| | | | | | |
________|_______|______|_____|_____|_____|_____|
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.
B. 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? Yes _______ No _______ (32)
(Ignore an occasional cough)
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)
___________________________________________________________________
C. 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 Yes _______ No ______ (38)
days for as much as three months each year?
If `Yes' to question (33) or (38):
(cough)
How long have you had this phlegm? (1) ____ 2 years or less (39)
(Write in number of years) (2) ____ More than 2 year-9 years
(3) ____ 10-19 years
(4) ____ 20+ years
* These words are for subjects who work at night
D. CHEST ILLNESSES
In the past three years, have you had a period (1) ____ No (40)
of (increased) *cough and phlegm lasting for
3 weeks or more? (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 Yes _______ No _______ (42)
any of these illnesses?
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 _______
E. 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 Yes ___ No ___ (46)
from the mill)
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 (1) ___ Before entering the mill (48)
Monday does your chest feel tight or your
breathing difficult? (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
F. 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 Yes _______ No _______ (52)
hill?
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 Yes _______ No _______ (57)
slight hill?
If `No', grade is 1.
If `Yes', proceed to next question.
Do you get short of breath walking with other Yes _______ No _______ (58)
people at ordinary pace on the level?
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 ofbreath on washing or dressing? Yes _______ No _______ (60)
If `No', grade is 4.
If `Yes', grade is 5.
B. Grd. __________________ (61)
G. 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)
H. TOBACCO SMOKING*
Do you smoke?
Record 'Yes', if regular smoker up
to one month ago (Cigarettes, cigar Yes _______ No _______ (66)
or pipe)
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 |
|_______|_______|____|_____|_____|_____|_____|_____|_____|_______|
|Cigar- | | | | | | | | | |
| ettes | | | | | | | | | | (68)
|_______|_______|____|_____|_____|_____|_____|_____|_____|_______|
|Pipe | | | | | | | | | | (69)
|_______|_______|____|_____|_____|_____|_____|_____|_____|_______|
|Cigars | | | | | | | | | | (70)
|_______|_______|____|_____|_____|_____|_____|_____|_____|_______|
If cigarettes, how many packs per day? (1) __ Less than 1/2 pack (71)
(Write in number of cigarettes)
(2) __ 1/2 pack, but less than 1 pack
(3) __ 1 pack, but less than 1 1/2 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.
I. 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? Yes _______ No _______ (78)
If yes, specify.
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)
[43 FR 27394, June 23, 1978; 43 FR 35035, Aug. 8, 1978, as amended at 45 FR 67340, Oct. 10, 1980; 50 FR 51173, Dec. 13, 1985; 51 FR 24325, July 3, 1986; 54 FR 24334, June 7, 1989; 61 FR 5508, Feb. 13, 1996; 63 FR 1290, Jan. 8, 1998; 65 FR 76567, Dec. 7, 2000; 70 FR 1142, Jan. 5, 2005; 71 FR 16672, 16673, Apr. 3, 2006; 71 FR 50189, Aug. 24, 2006; 73 FR 75586, Dec. 12, 2008; 76 FR 33609, June 8, 2011; 77 FR 17782, Mar. 26, 2012; 84 FR 21492, May 14, 2019]