Personal Injury
Construction Research Center News & Warnings OSHA Guidelines Authority for 1910 Subpart Z
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Personal Injury
Construction Research Center News & Warnings OSHA Guidelines Authority for 1910 Subpart Z
Occupational Safety and Health Standards: Toxic and Hazardous Substances, Respiratory questionnaire
If you are the victim of construction accidents, use this page to conduct research. To have your case evaluated immediately, please fill out our form. Read more about the Occupational Safety and Health Standards, 1910.1043 App B-I, Toxic and Hazardous Substances, Respiratory questionnaire.
Appendix B-I
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)| | | | | | | | | |
| | | | | | | | | |
________|_______|______|_____|_____|____|____|_____|_____|______|
Continued --
Work- (26) (27) (28) (29) (30)
room
Number Spool Warp Slash Weave Other
________________________________________________
| | | | | | |
AT RISK | 1 | | | | | |
(cotton |_______|______|_____|_____|_____|_____| & cotton| | | | | | |
blend) | 2 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 3 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 4 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 5 | | | | | |
|_______|______|_____|_____|_____|_____|
| | | | | | |
| 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
thing in the morning? ___________________________________
Yes _______ No _______ (31)
(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 day or at night? ____________________________________
(Ignore an occasional cough.) Yes _______ No _______ (32)
If `Yes' to either question (31-32):
Do you cough like this on most
days for as much as three
months a year? ____________ Yes _______ No _______ (33)
Do you cough on any particular
day of the week?
Yes _______ No _______ (34)
(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 any phlegm like
this on most days for as
much as three months each year? Yes _______ No ______ (38)
If `Yes' to question (33) or (38):
(cough) (1) ____ 2 years or less (39)
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. CHEST ILLNESSES
In the past three years, (1) ____ No (40)
have you had a period
of (increased) *cough (2) ____ Yes, only one
and phlegm lasting for period
3 weeks or more? _________
(3) ____ Yes, two or more
periods
*For subjects who usually have phlegm
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?) Yes _______ No _______ (41)
If `Yes' to (41):
Did you bring up (more) phlegm than
usual in any of these illnesses?
Yes _______ No _______ (42)
If `Yes' to (42):
During the past three years have
you had:
Only one such illness
with increased phlegm? (1) _______ (43)
More than one such illness: (2) _______ (44)
Br. Grade _______
E. TIGHTNESS
Does your chest ever feel tight or
your breathing become difficult? ________________________
Yes _______ No _______ (45)
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 _______ (46)
If `Yes': Which day? (3) (4) (5) (6) (7) (8)
Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (47)
(1) / \ (2)
Sometimes Always
If `Yes' Monday At what time on
Monday does your chest feel
tight or your breathing difficult?
(1) _____ Before entering the mill (48)
(2) _____ After entering the mill
(Ask only if NO to Question (45)
In the past, has your chest ever
been tight or your breathing
difficult on any particular
day of the week? ________________________________________
Yes _______ No _______ (49)
If `Yes': Which day? (3) (4) (5) (6) (7) (8)
Mon. ^ Tues. Wed. Thur. Fri. Sat. Sun. (50)
(1) / \ (2)
Sometimes Always
F. BREATHLESSNESS
If disabled from walking by any
condition other than heart or
lung disease put "X" here and
leave questions (52-60) unasked. ________________________ (51)
Are you ever troubled by
shortness of breath, when
hurrying on the level or
walking up a slight hill? _______________________________
Yes _______ No _______ (52)
If `No', grade is 1.
If `Yes', proceed to next question.
Do you get short of breath walking
with other people at an ordinary
pace on the level? ______________________________________
Yes _______ No _______ (53)
If `No', grade is 2.
If `Yes', proceed to next question.
Do you have to stop for breath
when walking at your own pace
on the level? ________________ Yes _______ No _______ (54)
If `No', grade is 3.
If `Yes', proceed to next question.
Are you short of breath on
washing or dressing? ____________________________________
Yes _______ No _______ (55)
If `No', grade is 4.
If `Yes' grade is 5.
Dyspnea Grd. ________________ (56)
ON MONDAYS
Are you ever troubled by shortness
of breath, when hurrying on the
level or walking up a slight hill? ______________________
Yes _______ No _______ (57)
If `No', grade is 1.
If `Yes', proceed to next question.
Do you get short of breath walking
with other people at ordinary
pace on the level? ______________________________________
Yes _______ No _______ (58)
If `No', grade is 2.
If `Yes', proceed to next question.
Do you have to stop for breath
when walking at your own pace
on level ground? ________________________________________
Yes _______ No _______ (59)
If `No', grade is 3.
If `Yes', proceed to next question.
Are you short of breath on washing
or dressing? ____________________________________________
Yes _______ No _______ (60)
If `No', grade is 4.
If `Yes', grade is 5.
B. Grd. __________________ (61)
G. OTHER ILLNESSES AND ALLERGY HISTORY
Do you have a heart condition for
which you are under a doctor's care? ____________________
Yes _______ No ________ (62)
Have you ever had asthma? Yes _______ No ________ (63)
If `Yes', did it begin: (1) _______ Before age 30
(2) _______ After age 30
If `Yes' before 30 did you have
asthma before ever going to work
in a textile mill? ________________________________________
Yes _______ No ________ (64)
Have you ever had hay fever or
other allergies (other than above)? _____________________
Yes _______ No ________ (65)
H. TOBACCO SMOKING*
Do you smoke?
Record `Yes', if regular smoker up
to one month ago (Cigarettes, cigar
or pipe) ________________________________________________
Yes _______ No _______ (66)
If `No' to (63)
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.) ______________________
Yes _______ No _______ (67)
If `Yes' to (63) or (64), what have
you smoked and for how many years?
(Write in specific number of years
in the appropriate square)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
__________________________________________________________
| | | | | | | | | | |
|Years |< 5 |5-9 |10-14|15-19|20-24|25-29|30-34|35-39| >40|
|_______|____|____|_____|_____|_____|_____|_____|_____|____|
|Cigar- | | | | | | | | | |
| ettes | | | | | | | | | | (68)
|_______|____|____|_____|_____|_____|_____|_____|_____|____|
|Pipe | | | | | | | | | | (69)
|_______|____|____|_____|_____|_____|_____|_____|_____|____|
|Cigars | | | | | | | | | | (70)
|_______|____|____|_____|_____|_____|_____|_____|_____|____|
If cigarettes, how many packs per day?
(Write in number of cigarettes)
(1) ______ Less than 1/2 pack (71)
(2) ______ 1/2 pack, but less than 1 pack
(3) ______ 1 pack, but less than 1 1/2
packs
(4) ______ 1 1/2 packs or more
Number of years _______________________________________ (72, 73)
If an ex smoker (cigarettes, cigar
or pipe), how long since you s
topped? (Write in number of years) ________________________ (74)
(1) ______ 0-1 year
(2) ______ 1-4 years
(3) ______ 5-9 years
(4) ______ 10+ years
* Have you changed your smoking
habits since last interview?
If yes, specify what changes.
I. OCCUPATIONAL HISTORY**
Have you ever worked in:
A foundry? (As long as one year) ________________________
Yes _______ No _______ (75)
Stone or mineral mining, quarry
or processing? (As long as one year) ____________________
Yes _______ No _______ (76)
Asbestos milling or processing? ________________________
Yes _______ No _______ (77)
Other dusts, fumes or smoke?
If yes, specify. ________________________________________
Yes _______ No _______ (78)
Type of exposure ________________________________________
Length of exposure ______________________________________
|** Ask only on first interview.
At what age did you first go to work in a textile mill?
(Write in specific age in appropriate square)
(1) (2) (3) (4) (5) (6)
___________________________________________
| | | | | | |
|< 20 | 20-24 | 25-29 | 30-34 | 35-39 | 40+ |
|_____|_______|_______|_______|_______|_____|
| | | | | | |
|_____|_______|_______|_______|_______|_____|
When you first worked in a textile mill, did you
work with:
(1) ______ Cotton or cotton blend (79)
(2) ______ Synthetic or wool (80)
Act now! It is essential that you inquire about your case as soon as possible. Litigation may be the only way to receive the damages to which you may be entitled, such as medical and health care bills, lost or diminished wages, and financial compensation to family in the case of death. Your individual state's law may limit your time to bring a legal claim to protect your rights. You need to have your construction accidents claim evaluated immediately!
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