Flavoring workers - Questionnaire

Appendix D.3: Flavoring Workers Questionnaire (English)

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

FLAVORING WORKERS QUESTIONNAIRE

Section I: Identification and Demographic Information

1. Survey Date: __ __/__ __/2014

2. Name: _________________ ______ _______________________

First MI Last

3. Home Address: ___________________________________________

(Number, Street, and/or Rural Route)

______________________ _____ __________

(City) (State) (Zip Code)

4. Home Telephone Number: ( __ __ __) __ __ __ - __ __ __ __

5. Date of Birth: __ __ / __ __ / __ __ __ __

Month Day Year

6. Gender: 1.____ Male

2.____ Female

7. Ethnicity (Please choose one):

1.____ Hispanic or Latino

0.____ Not Hispanic or Latino

8. Race (Please choose all that apply):

1.____ American Indian or Alaska Native

2.____ Asian

3.____ Black or African American

4.____ Native Hawaiian or Other Pacific Islander

5.____ White

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

If you were to move, is there someone who would know how to contact you?

9. Name: _________________ ______ _______________________

First MI Last

10. Relationship to you:________________________________________

11. Address: _________________________________________________

(Number, Street, and/or Rural Route)

______________________ _____ __________

(City) (State) (Zip Code)

12. Telephone Number: ( __ __ __) __ __ __ - __ __ __ __

Section II. Health Information

I’m going to ask you some questions about your health. The answer to many of these questions will be “Yes” or “No”. If you are unsure about whether to answer “Yes” or “No”, then please answer “No”.

13. During the last 12 months, have you had any trouble with your breathing? 1.Yes ___ 0.No ___

IF YES:

a) Which of the following statements best describes your breathing?

1. ___I only rarely have trouble with my breathing

2. ___I have regular trouble with my breathing but it always gets completely better

3. ___My breathing is never quite right

14. Do you usually have a cough? 1.Yes ___ 0.No ___

(Count cough with first smoke or on first going out-of-doors.

Exclude clearing of throat.)

IF YES:

a) Do you usually cough on most days for 3 consecutive months or more 1.Yes ___ 0.No ___

during the year?

b) In what year did this cough begin? __ __ __ __

Year

15. Do you usually bring up phlegm from your chest? 1.Yes ___ 0.No ___

(Count phlegm with first smoke or on first going out-of-doors.

Exclude phlegm from the nose. Count swallowed phlegm.)

IF YES:

a) Do you usually bring up phlegm on most days for 3 consecutive months 1.Yes ___ 0.No ___

or more during the year?

b) In what year did this phlegm begin? __ __ __ __

Year

16. Have you ever had wheezing or whistling in your chest? 1.Yes ___ 0.No ___

IF YES:

a) Have you had this wheezing or whistling when you did not have a cold? 1.Yes ___ 0.No ___

b) In what year did this wheezing or whistling first begin? __ __ __ __

Year

c) During the last 12 months, have you had this wheezing or whistling in your 1.Yes ___ 0.No ___

chest when you did not have a cold?

17. Have you ever had an attack of wheezing that has made you feel

short of breath? 1.Yes ___ 0.No ___

IF YES:

a) In what year did this wheezing first begin? __ __ __ __

Year

b) During the last 12 months, have you had an attack of wheezing that 1.Yes ___ 0.No ___

has made you feel short of breath?

18. Have you ever woken up with a feeling of tightness in your chest? 1.Yes ___ 0.No ___

IF YES:

a) In what year did you first notice this chest tightness? __ __ __ __

Year

b) During the last 12 months, have you woken up with a feeling 1.Yes ___ 0.No ___

of chest tightness?

IF NO:

c) When did this chest tightness stop? __ __ / __ __ __ __

Month Year

19. Are you troubled by shortness of breath when hurrying on level ground 1.Yes ___ 0.No ___ or walking up a slight hill?

IF YES:

a) Do you get short of breath walking with people of your own age on 1.Yes ___ 0.No ___

level ground?

b) Do you ever have to stop for breath when walking at your own pace 1.Yes ___ 0.No ___

on level ground?

c) Do you ever have to stop for breath after walking about 100 yards 1.Yes ___ 0.No ___

(or after a few minutes) on level ground?

d) Are you too breathless to leave the house or breathless when dressing 1.Yes ___ 0.No ___

or undressing?

e) In what year did this shortness of breath start? __ __ __ __

Year

20. In the last 4 weeks have you used any prescription or over-the-counter medications, including inhalers and/or pills, for breathing problems? 1.Yes ___ 0.No ___

IF YES:

a) Please list: _____________________________________________________________________

21. Have you ever been told by a physician or other health professional that you had any of the following conditions?

Conditions	Told by a physician you had?	Year of first diagnosis?
a) Hay fever or nasal allergies	1. Yes ___  0.No ___
b) Heart disease	1. Yes ___  0.No ___
c) Chronic bronchitis	1. Yes ___  0.No ___
d) Emphysema	1. Yes ___  0.No ___
e) Chronic obstructive pulmonary disease (COPD)	1. Yes ___  0.No ___
f) Hypersensitivity pneumonitis	1. Yes ___  0.No ___
g) Chemical pneumonitis	1. Yes ___  0.No ___
h) Bronchiolitis obliterans	1. Yes ___  0.No ___
i) Interstitial lung disease	1. Yes ___  0.No ___
j) Gastroesophageal reflux disease (GERD)	1. Yes ___  0.No ___
k) Vocal cord dysfunction	1. Yes ___  0.No ___
l) Sarcoidosis of the lung	1. Yes ___  0.No ___
m) Asthma	1. Yes ___  0.No ___
IF YES: n) Do you still have asthma?	1. Yes ___  0.No ___

22. Have you ever been told by a physician or other health professional that you had any other respiratory condition?

1.Yes ___ 0.No ___

IF YES:

a) What was it? _____________________________________________________________________

b) In what year were you first told you had this respiratory condition? __ __ __ __

Year

23. Are there any other respiratory problems that we have not already 1.Yes ___ 0.No ___

discussed that you would like us to know about?

IF YES:

a) Please describe ___________________________________________________________________

Section III. Work History

24. I’m now going to ask you some questions about where you have worked, starting with your first job. We will then move up to the present time.

Company	Job Title	Start Mo/Yr	End Mo/Yr	Major Work Areas (Flavorings only)	Other Work Areas (Flavorings only)	Do/Did you pour or scoop flavorings in this job (Flavorings only)	Reason Left	Comments

25. Do/Did you ever enter the flavoring room? 1.Yes ___ 0.No ___

Section IV. Other Exposures

26. Have you ever:

a) Worked in mining? 1.Yes ___ 0.No ___

IF YES: _____ Years

b) Worked in farming? 1.Yes ___ 0.No ___

IF YES: _____ Years

c) Worked in chemical manufacturing like explosives, dyes, lacquers, and celluloid?

1.Yes ___ 0.No ___

IF YES: _____ Years

d) Been exposed to fire smoke? (Do not count campfires, stoves.) 1.Yes ___ 0.No ___

IF YES: _____ Years

e) Been exposed to irritant gases like chlorine, sulfur dioxide, ammonia, and phosgene?

1.Yes ___ 0.No ___

IF YES: _____ Years

f) Been exposed to mineral dusts including coal, silica, and talc? 1.Yes ___ 0.No ___

IF YES: _____ Years

g) Been exposed to grain dusts? 1.Yes ___ 0.No ___

IF YES: _____ Years

h) Been exposed to oxides of nitrogen including silo gas? 1.Yes ___ 0.No ___

IF YES: _____ Years

i) Been exposed to asbestos? 1.Yes ___ 0.No ___

IF YES: _____ Years

j) Outside of the flavoring plant (or microwave popcorn plant), have you ever been exposed to any chemical or substance that affected your breathing? 1.Yes ___ 0.No ___

IF YES, describe the exposure:______________________

Section V. Tobacco Use

27. Have you ever smoked cigarettes? 1.Yes ___ 0.No ___

(NO if less than 20 packs of cigarettes in a lifetime or

less than 1 cigarette a day for 1 year.)

IF YES:

a) How old were you when you first started smoking regularly? ________Years Old

b) Over the entire time that you have smoked, what is the average number

of cigarettes that you smoked per day? _______Cigarettes/Day

c) Do you still smoke cigarettes? 1.Yes ___ 0.No ___

IF NO:

d) How old were you when you stopped smoking regularly? ________Years Old