This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at http://www.dir.ca.gov/od_pub/disclaimer.html.

Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 109. Hazardous Substances and Processes

Return to index
New query

§5190. Cotton Dust, Appendix B-III

                           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)|       |      |     |     |    |    |     |     |      |
        |       |      |     |     |    |    |     |     |      |
________|_______|______|_____|_____|____|____|_____|_____|______|


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' first day of employee's work week:

If 'Yes' first day of employee's work week: At what time
                 on the first day of
				 your work week does
                 your chest feel
                 tight or your
                 breathing
                 difficult?

                         (1)  _____ Before entering the mill  (42)
                         (2)  _____ After entering the mill


   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
If 'Yes' first day of employee's work week:

E.  TOBACCO SMOKING

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

Go BackGo Back to Article 109 Table of Contents