• 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]