Regulations (Standards - 29 CFR) - Table of Contents Regulations (Standards - 29 CFR) - Table of Contents
• Part Number: 1910
• Part Title: Occupational Safety and Health Standards
• Subpart: Z
• Subpart Title: Toxic and Hazardous Substances
• Standard Number: 1910.1043 App B-I
• Title: Respiratory questionnaire

                          Appendix B-I

                   RESPIRATORY QUESTIONNAIRE

A. IDENTIFICATION DATA

PLANT ______________________ SOCIAL SECURITY NO. ________________
                                                DAY  MONTH  YEAR
                                                     (fig-  (last
                                                      ures)   2
                                                             dig-
                                                             its)

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-   (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    |      |     |Rove |    |    |     |     |      |
       |_______|______|_____|_____|____|____|_____|_____|______|
       |       |      |     |     |    |    |     |     |      |
       |  5    |      |     |Thru |    |    |     |     |      |
       |       |      |     |Out  |    |    |     |     |      |
       |_______|______|_____|_____|____|____|_____|_____|______|
       |       |      |     |     |    |    |     |     |      |
       |  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 |_______|______|_____|_____|_____|_____| & cotton|       |      |     |     |     |     |
blend)  |  2    |      |     |     |     |     |
       |_______|______|_____|_____|_____|_____|
       |       |      |     |     |     |     |
       |  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? ____________________________________

   (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)

___________________________________________________________________


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 days for as
   much as three months each year?    Yes _______  No ______ (38)


If `Yes' to question (33) or (38):

                   (cough)         (1) ____ 2 years or less  (39)
     How long have you had
       this phlegm?
     (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. CHEST ILLNESSES

 In the past three years,          (1) ____ No               (40)
   have you had a period
   of (increased) *cough           (2) ____ Yes, only one
   and phlegm lasting for                   period
   3 weeks or more? _________
                                   (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 any of these illnesses?

                                     Yes _______  No _______ (42)

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
   from the mill) __________________________________________


                                     Yes _______  No _______ (46)



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
 Monday does your chest feel
 tight or your breathing difficult?

                        (1)  _____ Before entering the mill  (48)

                        (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 hill? _______________________________

                                     Yes _______  No _______ (52)

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 slight hill? ______________________

                                     Yes _______  No _______ (57)

If `No', grade is 1.
If `Yes', proceed to next question.

 Do you get short of breath walking
   with other people at ordinary
   pace on the level? ______________________________________

                                     Yes _______  No _______ (58)

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 of breath 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
   or pipe) ________________________________________________

                                     Yes _______  No _______ (66)


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?
 (Write in number of  cigarettes)

                  (1) ______ Less than 1/2 pack              (71)
                  (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 s
 topped? (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?
   If yes, specify. ________________________________________

                                     Yes _______  No _______ (78)

   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)


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