• Part Number:
    1910
  • Part Number Title:
    Occupational Safety and Health Standards
  • Subpart:
    1910 Subpart Z
  • Subpart Title:
    Toxic and Hazardous Substances
  • Standard Number:
  • Title:
    Abbreviated respiratory questionnaire
  • GPO Source:
        Appendix B-III -- ABBREVIATED RESPIRATORY QUESTIONNAIRE

               ABBREVIATED 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.


                      (19)  (20)        (21) (22)  (23)  (24)  (25)
            Work-
            room                      Card
            Number   Open  Pick   Area  #1   #2   Spin  Wind  Twist
____________________________________________________________________
  AT       |       |      |     |     |    |    |     |     |      |
 RISK      |  1    |      |     |Cards|    |    |     |     |      |
(cotton &  |_______|______|_____|_____|____|____|_____|_____|______| 
Cotton     |  2    |      |     |Draw |    |    |     |     |      |
blend)     |_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
           |  3    |      |     |Comb |    |    |     |     |      |
           |_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
           |       |      |     |Thru |    |    |     |     |      |
           |  4    |      |     |Out  |    |    |     |     |      |
           |_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
           |  5    |      |     |     |    |    |     |     |      |
           |       |      |     |     |    |    |     |     |      |
           |_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
           |  6    |      |     |     |    |    |     |     |      |
           |_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
           |  7    |      |     |     |    |    |     |     |      |
           | (all) |      |     |     |    |    |     |     |      |
___________|_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
Control    |       |      |     |     |    |    |     |     |      |
(synthetic |  8    |      |     |     |    |    |     |     |      |
& wool)    |       |      |     |     |    |    |     |     |      |
___________|_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
Ex-        |       |      |     |     |    |    |     |     |      |
Worker     |   9   |      |     |     |    |    |     |     |      |
___________|_______|______|_____|_____|____|____|_____|_____|______|
           |       |      |     |     |    |    |     |     |      |
(Cotton)   |       |      |     |     |    |    |     |     |      |
___________|_______|______|_____|_____|____|____|_____|_____|______|


Continued --

            Work-   (26)    (27) (28)  (29)   (30)
            room
            Number   Spool  Warp Slash Weave  Other
____________________________________________________
   AT      |       |      |     |     |      |     |
  RISK     |  1    |      |     |     |      |     |
(cotton    |_______|______|_____|_____|______|_____| 
blend)     |  2    |      |     |     |      |     |
           |_______|______|_____|_____|______|_____|
(Cotton &  |       |      |     |     |      |     |     
Cotton     |  3    |      |     |     |      |     |
Blend      |_______|______|_____|_____|______|_____|
           |       |      |     |     |      |     |
           |  4    |      |     |     |      |     |
           |_______|______|_____|_____|______|_____|
           |       |      |     |     |      |     |
           |  5    |      |     |     |      |     |
           |_______|______|_____|_____|______|_____|
           |       |      |     |     |      |     |
           |  6    |      |     |     |      |     |
           |_______|______|_____|_____|______|_____|
           |       |      |     |     |      |     |
           |  7    |      |     |     |      |     |
           | (all) |      |     |     |      |     |
___________|_______|______|_____|_____|______|_____|
           |       |      |     |     |      |     |
Control    |       |      |     |     |      |     |
(synthetic |  8    |      |     |     |      |     |
& 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 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?   (1) ____ 2 years or less

     (Write in number of years)           (2) ____ More than 2 years - 9 years

                                          (3) ____ 10-19 years

                                          (4) ____ 20+ years

* These words are for subjects who work at night

D. 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    (1)  _____ Before entering the mill  (42)
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 ______ (43)



If `Yes': Which day?   (3)   (4)   (5)    (6)   (7)   (8)
               Mon. ^ Tues.  Wed.  Thur.  Fri.  Sat.  Sun.                (44)
               (1) / \ (2)
          Sometimes    Always

E.  TOBACCO SMOKING

 * Have you changed your smoking habits since last interview?
   If yes, specify what changes.

[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 21512, May 14, 2019]