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-II
• Title: Respiratory questionnaire for non-textile workers for the cotton industry

                          Appendix B-II

                   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. SOCIAL SECURITY: (optional see below)

       ___ - __ - ____
__________________________________________________________________

5.  BIRTHDATE     (Mo.,  Day,  Yr.)

__________________________________________________________________

6.  AGE LAST BIRTHDAY

__________________________________________________________________

7.  SEX

   1. ______ 	Male       2. ______  Female
__________________________________________________________________

8.  ETHNIC GROUP OR ANCESTRY

   1. ____ White, not of Hispanic Origin

   2. ____ Black, not of Hispanic Origin

   3. ____ Hispanic

   4. ____ American Indian or Alaskan Native

   5. ____ Asian or Pacific Islander

   6. ____ Other: __________________________
__________________________________________________________________

9.  STANDING HEIGHT

   ________________ (cm)
__________________________________________________________________

10. WEIGHT

   ________________
__________________________________________________________________

11. WORK SHIFT

   1st ______     2nd ______    3rd  ______

__________________________________________________________________

12. 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       |________________________________________
                        |
   _____________________|________________________________________
__________________________________________________________________

13. APPROPRIATE INDUSTRY

   1. _____ Garnetting

   2. _____ Cottonseed Oil Mill

   3. _____ Cotton Warehouse

   4. _____ Utilization

   5. _____ Cotton Classification

   6. _____ Cotton Ginning
__________________________________________________________________

(Furnishing your Social Security number is voluntary. Your refusal
to provide this number will not affect any right, benefit, or
privilege to which you would be entitled if you did provide your
Social Security number. Your Social Security number is being
requested since it will permit use in future determinatiors in
statistical research studies.)
__________________________________________________________________


               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    |     |    |
        | 19__ |19__ |          | 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?               1. ____ Yes  2. ____ No
  (on 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
  year?                                     9. ____ NA

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 phlegm?  (1) ____ 2 years or less
  (cough) (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.



CHEST ILLNESS

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

                                      (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) phlegm     1. ____ Yes  2. ____ No
   than usual in any of these
   illnesses?

If YES to 12: During the past three
   years have you had:

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

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 does        _____ Before entering mill
   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         1. ____ Yes  2. ____ No
   ever 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           1. ____ Yes  2. ____ No
   shortness of breath, when
   hurrying on the level or
   walking up a slight hill?

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

23. Do you get short of breath         1. ____ Yes  2. ____ No
   walking with 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            1. ____ Yes  2. ____ No
   breath when 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         1. ____ Yes  2. ____ No
   washing or dressing?

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

26.                            Dyspnea Grd. __________________


ON MONDAYS:

27. Are you ever troubled by           1. ____ Yes  2. ____ No
   shortness of 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         1. ____ Yes  2. ____ No
   walking with 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            1. ____ Yes  2. ____ No
   breath when 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            1. ____ Yes  2. ____ No
   on washing or dressing?

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

                                  B. Grd. ___________________


OTHER ILLNESSES AND ALLERGY HISTORY

32. Do you have a heart                1. ____ Yes  2. ____ No
   condition for which 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          1. ____ Yes  2. ____ No
   have asthma before ever
   going to work in a textile
   mill?

35. Have you ever had hay fever        1. ____ Yes  2. ____ No
   or other 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)


   ______________________________________________________
              |    |     |       |       |       |
      Years   |< 5 | 5-9 | 10-14 | 15-19 | 20-24 | 25-29
   ___________|____|_____|_______|_______|_______|_______
              |    |     |       |       |       |
38. Cigarettes |    |     |       |       |       |
   ___________|____|_____|_______|_______|_______|_______
              |    |     |       |       |       |
39. Pipe       |    |     |       |       |       |
   ___________|____|_____|_______|_______|_______|_______
              |    |     |       |       |       |
40. Cigars     |    |     |       |       |       |
   ___________|____|_____|_______|_______|_______|_______


[38, 39, 40 CONTINUED]


   _____________________________________
              |       |       |
      Years   | 30-34 | 35-39 | >40
   ___________|_______|_______|_________
              |       |       |
38. Cigarettes |       |       |
   ___________|_______|_______|_________
              |       |       |
39. Pipe       |       |       |
   ___________|_______|_______|_________
              |       |       |
40. Cigars     |       |       |
   ___________|_______|_______|_________



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

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

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

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


   Type of exposure ___________________________

   Length of exposure _________________________

_____________________________________________________________________



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