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