|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.|
| Return to index
Flavor Worker Follow-Up Questionnaire
If you have not filled out a similar questionnaire in the past, please let the staff know that you need the “Initial Questionnaire” instead of this one.
About this Questionnaire:
The purpose of this questionnaire is to help health care providers monitor the health of workers in companies that manufacture food flavorings. It should be given to workers by health care providers who can follow up on the results. For more information, see www.dhs.ca.gov/ohb/flavorings.htm.
Please Read Before Beginning!
9. Do you have brown eyes?
□ Yes □ No (Go to Question 10)
9a. If Yes, please answer: Do your parents have brown eyes?
10. Do you have brown hair?
Note to Health Care Provider: This questionnaire is for health care providers to use to monitor the health of workers in companies that manufacture food flavorings. For more information, please see the guidance document, Medical Surveillance for Flavorings-Related Lung Disease Among Flavor Manufacturing Workers in California, which can be found at www.dhs.ca.gov/ohb/flavor-guidelines.pdf .
Today’s Date: __ __ / __ __ / __ __ __ __
(Month) (Day) (Year)
First Name:______________ Middle Initial:___ Last Name: ____________________________
(Number, Street, and/or Rural Route)
City:______________________________________ State:______ Zip:____________
Home Telephone Number: ( ) _______ - __________
Cell Phone Number: ( ) _______ - __________
Date of Birth: __ __ / __ __ / __ __ __ __
(Month) (Day) (Year)
1. Since the time of the last questionnaire, have you been troubled by shortness of breath when hurrying on level ground or walking up a slight hill?
□ Yes □ No (IF NO, please answer Question 2 next)
IF YES to Question 1:
1a) Do you get short of breath while walking with people □ Yes □ No
of your own age on level ground?
1b) Do you ever have to stop for breath when walking □ Yes □ No
at your own pace on level ground?
1c) Do you ever have to stop for breath either after walking about □ Yes □ No
100 yards or after a few minutes on level ground?
2. Do you usually have a cough?
□ Yes □ No (IF NO, please answer Question 3 next)
IF YES to Question 2:
2a) Did this usual cough start after the date of the last questionnaire? □ Yes □ No
2b) Do you have a cough on most days for 3 or more □ Yes □ No
consecutive months during the year?
3. Apart from when you have a cold, does your chest ever sound wheezy or whistling?
□ Yes □ No (IF NO, please answer Question 4 next)
IF YES to Question 3:
3a) In what year did you first experience wheezing or whistling __ __ __ __
in your chest when you did not have a cold? (Year)
4. Have you ever had asthma?
□ Yes □ No (IF NO, please answer Question 5 next)
IF YES to Question 4:
4a) Has a doctor ever told you that you had asthma? □ Yes □ No
4b) Do you still have asthma? □ Yes □ No
4c) Do you use any medication for your asthma? □ Yes □ No
5. Since the last questionnaire, have you had □ Yes □ No
attacks of bronchitis?
6. Has a doctor ever told you that you had chronic bronchitis?
□ Yes □ No (IF NO, please answer Question 7 next)
IF YES to Question 6:
6a) How old were you when you were diagnosed ______ Years old
with chronic bronchitis?
7. Since the date of the last questionnaire, have you had any episodes of □ Yes □ No
watery, itchy eyes?
8. Since the date of the last questionnaire, have you had any of the □ Yes □ No
following eye symptoms: red or burning eyes, eye pain,
eye swelling, or blurred vision?
9. Since the date of the last questionnaire, have you had to change your job, job duties, or work area at this plant because of cough, shortness of breath, or wheezing?
□ Yes □ No (IF NO, please answer Question 10 next)
IF YES to Question 9:
9a) Describe your job, job duties and work activities before the change:
10. Your current employer: _____________________________________________________________
11. Your current job title: _______________________________________________________________
12. Do you ever enter the liquid or powder production areas as part of your current job?
□ Yes □ No (IF NO, please answer Question 13 next)
IF YES to Question 12:
12a) On average, how often do you enter a liquid or powder production area in a week?
□ One time or less per week
□ 2 to 5 times per week
□ 6 to 10 times per week
□ More than 10 times per week
13. Check ALL work activities that you currently perform:
□ 13a) Pour, mix, measure, or fill containers with either small or large amounts of liquid ingredients or flavorings
□ 13b) Make small or large amounts of flavoring powders
□ 13c) Package small or large amounts of flavoring powders
□ 13d) Make small or large amounts of spray dry powders
□ 13e) Make small or large amounts of colors
□ 13f) Test product quality or develop new products
□ 13g) Repair or clean machinery
□ 13h) Work in warehouse
□ 13i) Ship or receive products
□ 13j) Drive a truck
□ 13k) Work in office
□ 13l) Other activities (Please describe)_______________________________________
14. At this plant, do you currently work as or have you ever worked as:
14a) a powder flavoring production worker? □ Yes □ No
14b) a liquid flavoring production worker? □ Yes □ No
14c) a spray drying production worker? □ Yes □ No
15. Since the date of the last questionnaire, have you been exposed to a spill or chemical release at work in this plant?
□ Yes □ No (IF NO, please answer Question 16 next)
IF YES to Question 15, please fill in the following table. List each spill or release on a separate line.
Chemical spilled or released
Date of spill or release
Did you have any symptoms following the spill or release?
If YES, what were
__ __ / __ __ __ __
□ No □ Yes
16. Do you now (or have you ever) worked with the following chemicals in liquid flavoring, powdered flavoring, or spray drying operations at this plant or any other flavoring plant:
16a) Diacetyl? □ Yes □ No □ Don’t Know
16b) Acetoin? □ Yes □ No □ Don’t Know
16c) Acetaldehyde? □ Yes □ No □ Don’t Know
16d) Benzaldehyde? □ Yes □ No □ Don’t Know
16e) Acetic acid? □ Yes □ No □ Don’t Know
Cigarette Smoking History
17. Do you currently smoke cigarettes?
□ Yes □ No
Thank you for your time!
Note: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.
1. New Appendix B2 filed 11-2-2010; operative 12-2-2010 (Register 2010, No. 45).
Go Back to Article 109 Table of Contents