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-II

                           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
If YES first day of employee's work week:

18. If YES first day of employee's work week:
    At what time on Monday does        _____ Before entering mill
    your chest feel tight or your
    breathing difficult?               _____ After entering mill


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
If YES first day of employee's work week:


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 THE FIRST DAY BACK TO WORK:

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     |    |     |       |       |       |
    ___________|____|_____|_______|_______|_______|_______


   _____________________________________
               |       |       |
       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 _________________________

_____________________________________________________________________


Go BackGo Back to Article 109 Table of Contents