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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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§5197. Appendix B1

Appendix B1

Flavor Worker Initial Questionnaire

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?

Although we would like everyone to answer the questions as completely as possible, you may skip any questions that you do not want to answer.

General Information

Today’s Date: __ __  /  __ __  /  __ __ __ __

                              (Month)   (Day)          (Year)

First Name:__________________  Middle Initial:___  Last Name: _______________________

Address:________________________________________________________________

   (Number, Street, and/or Rural Route)

City:______________________________________            State:______   Zip:____________    

Home Telephone Number:  (            ) _______ - __________

Cell Phone Number:   (            ) _______ - __________

Date of Birth:  __ __  /  __ __  /  __ __ __ __

                                  (Month)   (Day)        (Year)

Sex:                 Male          Female

Check the ONE category that best describes your race / ethnicity:   White, Non-Hispanic

                                                                                                            Black, Non-Hispanic

                                                                                                            Hispanic

                                                                                                                        Asian

                                                                                                Other (Please describe below)

                                                                                                      ________________________
Health Information

1.  Are you 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)  In what year did this shortness of breath begin?                                     __ __ __ __

                                                                                                                             (Year)

1b)  Do you get short of breath walking with people                                     □ Yes           □ No

       of your own age on level ground? 

1c)  Do you ever have to stop for breath when walking                                 □ Yes           □ No

       at your own pace on level ground?

1d)  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)  In what year did this usual cough begin?                                                             __ __ __ __

                                                                                                                              (Year)

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)  How old were you when the asthma began?                                          ______ Years old

4b)  Has a doctor ever told you that you had asthma?                    □ Yes           □ No

4c)  Do you still have asthma?                                                                        □ Yes           □ No

5.  Since you began working at this plant, 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.  During the past 12 months have you had any episodes of                                    Yes           □ No

  watery, itchy eyes?                                                                                      

8.  Since you began working at this plant, have you had any of the              □ Yes           □ No

     following eye symptoms:  red or burning eyes, eye pain,                         

     eye swelling, or blurred vision?

9.  Have you ever 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:

       ___________________________________________________________________________

       ___________________________________________________________________________

 

Work Information

 

10.  Your current employer: ­­­­_____________________________________________________________

11.  Month and year you were hired by this company:  __ __  /   __ __ __ __

                                                                                               (Month)        (Year)

12.  Your current job title: __________________________________________________________________

13.  Do you ever enter the work areas where diacetyl or                               □ Yes           □ No

       diacetyl-containing flavorings are used as part of your current job?

14.  Check ALL work activities that you currently perform:

□  14a)   Pour, mix, measure, or fill containers with liquid ingredients or flavorings         

    14b)   Make, use, or work with flavoring powders          

     14c)   Test product quality or develop new diacetyl-containing products                             

    14d) Repair or clean machinery that contained diacetyl or diacetyl-containing

           flavorings

     14e)   Work in warehouse with diacetyl-containing products

     14f)   Ship or receive diacetyl-containing products

     14g)   Other activities (Please describe)_______________________________________ 

15.  At this plant, do you currently work as or have you ever worked with a:

            15a) Powder flavoring or diacetyl-containing product?                     □ Yes           □ No

            15b) Liquid flavoring or diacetyl-containing product?                       □ Yes           □ No

                                               

16.  Please estimate the total number of years and months you have performed the following

       work activities at this plant. 

                                                                                    Total Years                 Total Months

      

16a)         Pour, mix, measure, or fill containers

                with liquid ingredients or flavorings           _______ years             _______ months

16b)        Make, use or work with flavoring powders            _______ years             _______ months

16c)         Test product quality or develop new

                diacetyl-containing products                       _______ years             _______ months

16d)        Repair or clean machinery that contained

                diacetyl or diacetyl-containing flavorings   _______ years             _______ months

16e)         Work in warehouse with

                diacetyl-containing products                       _______ years             _______ months

16f)         Ship or receive diacetyl-containing

                products                                                       _______ years             _______ months

16g)        Other (Please describe)______________   _______ years             _______ months

17.  Have you had cough or shortness of breath when you were around diacetyl-containing flavorings, ingredients or products used in this plant?

      □ Yes              □ No (IF NO, please answer Question 18 next)

IF YES to Question 17:

17a)  Please list those flavorings, ingredients and/or products: ______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

18.  Have you ever been exposed to a spill or chemical release at work in this plant?          

   □ Yes              □ No (IF NO, please answer Question 19 next)

IF YES to Question 18, 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

your symptoms?

 

    __ __  /   __ __ __ __

(Month)        (Year)

□ No      □ Yes

 

    __ __  /   __ __ __ __

(Month)        (Year)

□ No      □ Yes

 

    __ __  /   __ __ __ __

(Month)        (Year)

□ No      □ Yes

19.  Have you ever worked at any other plants that make, use or work with flavorings?

   □ Yes              □ No (IF NO, please answer Question 20 next)

IF YES to Question 19:

19a)  Total number of years and months worked at these other

         plants? (Example: if 2½ years, write as 2 years 6 months)        ____Years    ____Months

19b)  Did you pour, mix, use or work with liquid flavorings?                       □ Yes           □ No

19c)  Did you make use or work with powder flavorings?                            □ Yes           □ No

20.  Do you now (or have you ever) worked with the following chemicals in liquid flavoring, powdered flavoring, or other production operations at this plant or any other plant:

20a) Diacetyl?                                                 □ Yes              □ No            □ Don’t Know

20b) Acetoin?                                                             □ Yes              □ No            □ Don’t Know

20c) Acetaldehyde?                                        □ Yes              □ No            □ Don’t Know

20d) Benzaldehyde?                                       □ Yes              □ No            □ Don’t Know

20e) Acetic acid?                                            □ Yes              □ No            □ Don’t Know

Cigarette Smoking History

21.  Have you ever smoked cigarettes? (Answer NO if you have smoked fewer than 20 packs of cigarettes in your lifetime)

               Yes              □ No (IF NO, you have finished the survey)

IF YES to Question 21:

21a)  How old were you when you first started smoking regularly?              ______ Years old

21b)  Over the entire time that you have smoked, what is the average

          number of cigarettes that you smoked per day?                       ______ Cigarettes per day

21c)  Do you still smoke cigarettes?                                                              

     □ Yes              □ No

                         

                                    IF NO to Question 21c:

                                    21d)  How old were you when you stopped             

                                              smoking regularly?                                            ______ Years old

Note: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.

HISTORY

1. New Appendix B1 filed 11-2-2010; operative 12-2-2010 (Register 2010, No. 45).

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