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 https://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
Group 16. Control of Hazardous Substances
Article 109. Hazardous Substances and Processes
| Return to index New query |
§5190. Cotton Dust, Appendix B-III
Appendix B-III
ABBREVIATED 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 Names)
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 Yes _______ No ______ (31)
thing in the morning? __________
(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 Yes _______ No ______ (32)
day or at night? __________
(Ignore an occasional cough.)
If `Yes' to either question
(31-32):
Do you cough like this on Yes _______ No ______ (33)
most days for as much as three
months a year? ____________
Do you cough on any particular Yes _______ No ______ (33)
day of the week?
(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 phlegm like this
on most days for as much as three
months each year? ______________ Yes _______ NO ______ (38)
(cough) (1) ____ 2 years or less
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. TIGHTNESS
Does your chest ever feel
tight or your breathing
become difficult? ________ Yes _______ No ______ (39)
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 ______ (40)
If `Yes': Which day? (3) (4) (5) (6) (7) (8)
Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (41)
(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 the first day of
your work week does
your chest feel
tight or your
breathing
difficult?
(1) _____ Before entering the mill (42)
(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 ______ (43)
If `Yes': Which day? (3) (4) (5) (6) (7) (8)
Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (44)
(1) / \ (2)
Sometimes Always
If 'Yes' first day of employee's work week:
E. TOBACCO SMOKING
* Have you changed your smoking habits since last interview?
If yes, specify what changes.
Go Back to Article 109 Table of Contents