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

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§5190. Cotton Dust, Appendix B-I

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 Name)

                                                  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
    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(s)?     (3)   (4)   (5)    (6)   (7)   (8)
                  Mon. ^ Tues.  Wed.  Thur.  Fri.  Sat. Sun.  (47)
                  (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
  first day of your week does your chest feel
  tight or your breathing difficult?

                         (1)  _____ Before entering the mill  (48)

                         (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 _______ (49)



If 'Yes': Which day(s)?   (3)   (4)   (5)    (6)   (7)   (8)
                Mon. ^ Tues.  Wed.  Thur.  Fri.  Sat.  Sun.   (50)
                (1) / \ (2)
           Sometimes    Always

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

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 THE FIRST DAY BACK TO WORK:

  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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