Appendix B-II Respiratory Questionnaire for Non-Textile Workers for the Cotton Industry

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.)
__________________________________________________________________


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.

INDUSTRY AND LOCATION	TENURE OF EMPLYMENT		SPECIFIC OCCUPATION	AVERAGE NO. DAYS WORKED PER WEEK	HAZARDOUS HEALTH EXPOSURE ASSOCIATED WITH WORK
	FROM 19_	TO 19_			YES	NO	IF YES, DESCRIBE

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? (on getting up)* (Count a cough with first smoke or on "first going out of doors". Exclude clearing throat or a single cough.)		1. ____ Yes 2. ____ No
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, day of the week?		1. ____ Yes 2. ____ No
If YES:
5. Which day?     Mon.     Tue.     Wed.     Thur.     Fri.     Sat.     Sun. _____
PHLEGM
6. Do you usually bring up any 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.		1. ____ Yes 2. ____ No
7. Do you usually bring up an phlegm from your chest during the day or at night? (Accept twice or more.)		1. ____ Yes 2. ____ No
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 you had a period of (increased) cough and phlegm lasting for 3 weeks or more?		(1) ____ No (2) ____ Yes, only one period (3) ____ Yes, two or more periods
For subjects who usually have phlegm:
11. 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?)		1. ____ Yes 2. ____ No
If YES to 11:
12. Did you bring up (more) phlegm than usual in any of these illnesses?		1. ____ Yes 2. ____ No
If YES to 12: During the past three years have you had:
13. Only one such illness with increased phlegm?		1 ____ Yes 2. ____ No
14. More than one such illness:		1. ____ Yes 2. ____ No
		Br. Grade _____________
TIGHTNESS
15. Does your chest ever feel tight or your breathing become difficult?		1. ____ Yes 2. ____ No
16. Is your chest tight or your breathing difficult on any particular day of the week? (after a week or 10 days away from the mill)		1. ____ Yes 2. ____ No
17. If 'Yes": Which day? (3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (1) / \ (2) Sometimes Always
18. If YES Monday: At what time on Monday does	_____ Before entering mill
your chest feel tight or your breathing difficult?	_____ After entering mill
(ASK ONLY IF NO TO QUESTION 15)
19. In the past, has your chest ever been tight or your breathing difficult on any particular day of the week?		1. ____ Yes 2. ____ No
20. If 'Yes": Which day? (3) (4) (5) (6) (7) (8) Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (1) / \ (2) Sometimes Always
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 shortness of breath, when hurrying on the level or walking up a slight hill?		1. ____ Yes 2. ____ No
If NO, grade is 1. If YES, proceed to next question.
23. Do you get short of breath walking with other people at an ordinary pace on the level?		1. ____ Yes 2. ____ No
If NO, grade is 2. If YES, proceed to next question.
24. Do you have to stop for breath when walking at your own pace on the level?		1. ____ Yes 2. ____ No
If NO, grade is 3. If YES, proceed to next question.
25. Are you short of breath on washing or dressing?		1. ____ Yes 2. ____ No
If NO, grade is 4, If YES, grade is 5.
26	Dyspnea Grd. __________________
ON MONDAYS:
27. Are you ever troubled by shortness of breath, when hurrying on the level or walking up a slight hill?		1. ____ Yes 2. ____ No
If NO, grade is 1, If YES, proceed to next question.
28. Do you get short of breath walking with other people at an ordinary pace on the level?		1. ____ Yes 2. ____ No
If NO, grade is 2, If YES, proceed to next question.
29. Do you have to stop for breath when walking at your own pace on the level?		1. ____ Yes 2. ____ No
If NO, grade is 3, If YES, proceed to next question.
30. Are you short of breath on washing or dressing?		1. ____ Yes 2. ____ No
If NO, grade is 4, If YES, grade is 5.
	B. Grd. ___________________
OTHER ILLNESSES AND ALLERGY HISTORY
32. Do you have a heart condition for which you are under a doctor's care?		1. ____ Yes 2. ____ No
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 have asthma before ever going to work in a textile mill?		1. ____ Yes 2. ____ No
35. Have you ever had hay fever or other allergies (other than above)?		1. ____ Yes 2. ____ No
TOBACCO SMOKING
36. Do you smoke? Record Yes if regular smoker up to one month ago. (Cigarettes, cigar or pipe)		1. ____ Yes 2. ____ No
If NO to (33).
37. 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.		1. ____ Yes 2. ____ No
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

[38, 39, 40 CONTINUED]

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, quarrying or processing? (As long as one year)	1. ____ Yes 2. ____ No
46.	Asbestos milling or processing? (Ever)	1. ____ Yes 2. ____ No
47.	Cotton or cotton blend mill? (For controls only)	1. ____ Yes 2. ____ No
48.	Other dusts, fumes or smoke? If yes, specify.	1. ____ Yes 2. ____ No
	Type of exposure ___________________________
	Length of exposure _________________________