2.13 Respiratory Assessment

National Coal Workers' Health Surveillance Program (CWHSP)

Attachment 16

OMB: 0920-0020

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Attachment 16 –

Respiratory Assessment Form – Form 2.13


















































Form Approved

OMB No. 0920-0020

Exp. Date xx/xx/20xx


RESPIRATORY ASSESSMENT FORM


DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

COAL WORKERS’ HEALTH SURVEILLANCE PROGRAM (CWHSP)

Return To:


NIOSH

Coal Workers’ Health Surveillance Program

1095 Willowdale Road, M/S LB208

Morgantown, WV 26505

FAX: 304-285-6058

Miner Identification

Miner’s Name (Last)

(First)

(Middle)






Medical Record Number

Birth Date

Date Completed








Email Address







Mark an X for the best answer.


Medical Conditions

  1. Has a doctor, nurse, or other health professional EVER told you that you had any of the following?


NO

YES

Coronary heart disease?



Angina, also called angina pectoris?



A heart attack (myocardial infarction)?



A stroke?



High blood pressure or hypertension?



Asthma?



Emphysema?



Chronic bronchitis?



Rheumatoid arthritis?



COPD (Chronic Obstructive Pulmonary Disease)?




Respiratory Symptoms

  1. Do you usually have a cough, apart from colds?

If YES, answer 2a and 2b.

No

Yes

2a. Do you cough on most days* for 3 or more months during the year?

No

Yes

2b. About how many years have you had this cough?


Years

  1. Do you usually bring up phlegm from your chest, apart from colds? If YES, answer 3a and 3b.

No

Yes

3a. Do you bring up chest phlegm on most days* for 3 or more months during the year?

No

Yes

3b. About how many years have you had phlegm like this?


Years

* = Most days means 4 or more days each week.

CDC/NIOSH 2.13 Rev. 01/2015

Public reporting burden of this collection of information is estimated to average 5minutes 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA, 30333, ATTN: PRA (0920-0020).




Respiratory Symptoms (continued)

  1. In the last 12 months, have you had wheezing or whistling in your chest at any time? If YES, answer 4a and 4b.

No

Yes

4a. Mark one: Yes, I have wheezing only when I have a cold



Yes

OR Yes, I have wheezing sometimes when I don’t

have a cold


Yes

4b. Does the wheezing always clear when you cough?


No

Yes

  1. When you are away from the mine on days off, is this wheezing or whistling (mark one)

The same

Worse

Better

  1. In the past 12 months, have you had an episode of asthma or an asthma attack?

No

Yes

6a. If YES, about how old were you when you first had an attack of asthma?

Age

  1. Are you currently taking any medicine for your breathing? (including inhalers, aerosols, or pills)

No

Yes

7a. If YES, mark what you are currently taking:


Inhalers

Aerosols

Pills

  1. Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill? If YES, answer 8a.

No

Yes

8a. Do you have to walk slower than people of your age on level ground because of shortness of breath? If YES, answer 8b.

No

Yes

8b. About how many years have you had this shortness of breath?

Years


Smoking History

  1. Have you ever smoked cigarettes regularly? (Mark NO if you smoked less than 100 cigarettes in your entire life; 100 cigarettes = 5 packs) If YES, answer 9a thru 9d.

No

Yes

9a. On average, for the entire time that you smoked, about how many cigarettes did you smoke per day?

(1 pack = 20 cigarettes)

Cigarettes per Day

9b. About how old were you when you first started smoking cigarettes regularly?

Age

9c. Do you still smoke cigarettes?


No

Yes

If NO, about how old were you when you completely stopped smoking?

Age

If YES, would you like to quit smoking now?


Yes

Maybe

No

9d. During the time you were a smoker, did you ever stop smoking for 6 months or more?

No

Yes

If YES, about how long did you stop smoking altogether? (Mark the total number of years that you stopped smoking during the time you were a smoker)


Years

  1. Do you use any other inhaled tobacco or nicotine products (pipes, cigars, electronic cigarettes, e-cigarettes etc.)?

No

Yes

10a. If YES, do you use them (mark one)


Every Day

Most Days

Some Days

* = Most days means 4 or more days each week.

CDC/NIOSH 2.13 Rev. 01/2015


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