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// CODE SNIPPET

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

OSHA 1910 General Industry > Z Toxic and Hazardous Substances > 1910.1043 Cotton Dust > B-II Respiratory Questionnaire for Non-Textile Workers for the Cotton Industry
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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.

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



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?
(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 _________________________

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