US Dept of Labor

Occupational Safety & Health AdministrationWe Can Help

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-III
• Title: Abbreviated respiratory questionnaire
• GPO Source: e-CFR

                          Appendix B-III

               ABBREVIATED 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           Yes _______  No ______ (31)
 thing in the morning? __________
   (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      Yes _______  No ______ (32)
 day or at night? __________
   (Ignore an occasional cough.)

If `Yes' to either question
 (31-32):

 Do you cough like this on            Yes _______  No ______ (33)
 most days for as much as three
 months a year? ____________

 Do you cough on any particular       Yes _______  No ______ (33)
 day of the week?


                      (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)


                   (cough)         (1) ____ 2 years or less
     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.  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 Monday does
                your chest feel
                tight or your
                breathing
                difficult?

                        (1)  _____ Before entering the mill  (42)
                        (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.


Next Standard (1910.1043 App C)

Regulations (Standards - 29 CFR) - Table of Contents

Thank You for Visiting Our Website

You are exiting the Department of Labor's Web server.

The Department of Labor does not endorse, takes no responsibility for, and exercises no control over the linked organization or its views, or contents, nor does it vouch for the accuracy or accessibility of the information contained on the destination server. The Department of Labor also cannot authorize the use of copyrighted materials contained in linked Web sites. Users must request such authorization from the sponsor of the linked Web site. Thank you for visiting our site. Please click the button below to continue.

Close