• 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 for Non-Textile Workers for the Cotton Industry
  • GPO Source:
    APPENDIX B-II --RESPIRATORY QUESTIONNAIRE FOR NON-TEXTILE
                WORKERS FOR THE COTTON INDUSTRY

    Respiratory Questionnaire for Non-Textile Workers for the
                         Cotton Industry

__________________________________________________________________
Identification No.                   Interviewer Code

__________________________________________________________________

Location                             Date of Interview

__________________________________________________________________


                           A.  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.  SEX

   1. ______ 	Male       2. ______  Female


6.  ETHNIC GROUP OR ANCESTRY (Check all that apply) 

   1. ____ White

   2. ____ Black or African American

   3. ____ Asian

   4. ____ Hispanic or Latino

   5. ____ American Indian or Alaska Native

   6. ____ Native Hawaiian or Other Pacific Islander


7.  STANDING HEIGHT

   ________________ (in)


8. WEIGHT (lbs)

   ________________
9. WORK SHIFT

   1st ______     2nd ______    3rd  ______


10. 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       |________________________________________
                        |
   _____________________|________________________________________
__________________________________________________________________

11. APPROPRIATE INDUSTRY

   1. _____ Garnetting

   2. _____ Cottonseed Oil Mill 

   3. _____ Cotton Warehouse 

   4. _____ Utilization

   5. _____ Cotton Classification

   6. _____ Cotton Ginning
__________________________________________________________________


               B. 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.

________________________________________________________________
         |             |          |         |
         |  TENURE OF  |          | AVERAGE |  HAZARDOUS HEALTH
INDUSTRY | EMPLOYMENT  | SPECIFIC |   NO.   | EXPOSURE ASSOCIATED
 AND     |_____________|OCCUPATION|  DAYS   |    WITH WORK
LOCATION |      |      |          | WORKED  |____________________
         | FROM | TO   |          |  PER    |     |    |
         |(year)|(year)|          | WEEK    | YES | NO | IF YES,
         |      |      |          |         |     |    | DESCRIBE
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________
         |      |      |          |         |     |    |
_________|______|______|__________|_________|_____|____|_________



                       C. 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              1. ____ Yes  2. ____ No
   getting up)* (Count a cough
   with first smoke or on "first
   going out of doors". Exclude
   clearing throat or a single 
   cough.) 

2. Do you usually cough during         1. ____ Yes  2. ____ No
   the day or at night? (Ignore an
   occasional cough.) 

If YES to either 1 or 2:

3. Do you cough like this on days      1. ____ Yes  2. ____ No
  for as much as three months a        3. ____ NA
  year?                                

4. Do you cough on any particular      1. ____ Yes  2. ____ No
  day of the week?

If YES:

5. Which day?  Mon.  Tue.  Wed.  Thur.  Fri.  Sat.  Sun. _____



PHLEGM


6. Do you usually bring up any         1. ____ Yes  2. ____ No
   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.

7. Do you usually bring up any         1. ____ Yes  2. ____ No
   phlegm from your chest during
   the day or at night?
   (Accept twice or more.) 

If YES to either question 6 or 7:

8. Do you bring up phlegm like         1. ____ Yes  2. ____ No
  this on most days for as much
  as three months each year?

If YES to question 3 or 8:

9. How long have you had this  (1) ____ 2 years or less
   phlegm?                     (2) ____  More than 2 years - 9 years
   (cough)                     (3) ____ 10-19 years              
   (Write in number of years)  (4) ____ 20+ years


*These words are for subjects who work at night. 

CHEST ILLNESS

10. In the past three years, have      (1) ____ No
    you had a period of
    (increased) cough and phlegm       (2) ____ Yes, only one period
    lasting for 3 weeks or more?     
                                       (3) ____ Yes, two or more periods 

For subjects who usually have
phlegm:

11.  During the past 3 years have      1. ____ Yes  2. ____ No
     you had any chest illness
     which has kept you off work,
     indoors at home or in bed?
     (For as long as one week, flu?)

If YES to 11:

12. Did you bring up (more)            1. ____ Yes  2. ____ No
    phlegm than usual in any of
    these illnesses? 

13. Only one such illness with         1. ____ Yes  2. ____ No
   increased phlegm?

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          1. ____ Yes  2. ____ No
   tight or your breathing
   become difficult?

16. Is your chest tight or your        1. ____ Yes  2. ____ No
   breathing difficult on any
   particular day of the week?
   (after a week or 10 days away 
   from the mill)


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                  _____ Before entering mill
   does your chest feel tight or
   your breathing difficult?               _____ After entering mill


(Ask only if NO to Question (15)) 


19.  In the past, has your chest ever   1. ____ Yes  2. ____ No
     been tight or your breathing
     difficult on any particular day of
     the week? 


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 1. ____ Yes  2. ____ No
    other people at an ordinary pace on the
    level? 

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

24. Do you have to stop for breath when     1. ____ Yes  2. ____ No
    walking at your own pace on the level?

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

25. Are you short of breath on washing or   1. ____ Yes  2. ____ No
    dressing? 

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

26.                                 Dyspnea Grd. __________________


ON MONDAYS:

27. Are you ever troubled by shortness of   1. ____ Yes  2. ____ No
    breath, when hurrying on the level or
    walking up a slight hill? 

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

28. Do you get short of breath walking with 1. ____ Yes  2. ____ No
    other people at an ordinary pace on the
    level? 

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

29. Do you have to stop for breath when     1. ____ Yes  2. ____ No
    walking at your own pace on the level? 

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

30. Are you short of breath on washing or   1. ____ Yes  2. ____ No
    dressing? 

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 1. ____ Yes  2. ____ No
    you are under a doctor's care??

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   1. ____ Yes  2. ____ No
    before ever going to work in a textile
    mill? 

35. Have you ever had hay fever or other    1. ____ Yes  2. ____ No
    allergies (other than above)?



TOBACCO SMOKING

36. Do you smoke?                           1. ____ Yes  2. ____ No
    Record Yes if regular smoker up to one
    month ago. (Cigarettes, cigar or pipe) 

If NO to (33).

37. Have you ever smoked?                   1. ____ Yes  2. ____ No
    (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.) 

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?                         1. ____ Yes  2. ____ No
   (As long as one year)

45. Stone or mineral mining, quarrying 1. ____ Yes  2. ____ No
   or
    processing?
    (As long as one year) 

46. Asbestos milling or processing?    1. ____ Yes  2. ____ No
    (Ever)

47. Cotton or cotton blend mill?       1. ____ Yes  2. ____ No
    (For controls only) 

48. Other dusts, fumes or smoke?       1. ____ Yes  2. ____ No
    If yes, specify. 


   Type of exposure ___________________________

   Length of exposure _________________________

_____________________________________________________________________


[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 21502, May 14, 2019]