|-----------------------------------------------------------------------------| | DEPARTMENT OF HEALTH AND HUMAN SERVICES | | | | | | Public Health Service | | Centers for Disease Control and Prevention | | National Institute for Occupational Safety and Health | | Morgantown, West Virginia 26505 | | | | | | | |-----------------------------------------------------------------------------| Study of Coalworkers' Pneumoconiosis This report is authorized by the Federal Coal Mine Health and Safety Act of 1969 (PL 91-173). While your response is voluntary, your cooperation is necessary for the understanding of health factors related to conditions of the underground mining environment. ID __________ DATE: ___/___/___ INTERVIEWER NUMBER: ________ PFT NUMBER: ______ X-RAY NUMBER: _______ B=Before shift When did interview take place? ______ A=After shift N=Neither B or A T=Telephone A.IDENTIFICATION 1. NAME:____________________ ____________________ ___ (Last) (First) (MI) 2. CURRENT ADDRESS: STREET _________________________ CITY ____________________ STATE ___ ZIP ________ 3. PHONE NUMBER: (_____) ____ - __________ 4. SOCIAL SECURITY NUMBER: _____ - ___ - __________ 5. BIRTHDATE: ___/___/___ 6. AGE LAST BIRTHDAY ______ mm dd yy 7. SEX 1 M 2 F 8. RACE 1. AMERICAN INDIAN __ 2. ASIAN __ 3. BLACK __ 4. HISPANIC __ 5. WHITE __ 9. MARITAL STATUS: 1. MARRIED __ 2. WIDOWED __ 3. DIVORCED __ 4. SEPARATED __ 5. NEVER MARRIED __ 10. STANDING HEIGHT _____.___ (cms) 11. WEIGHT _____.____ (kgs) 12. WHAT WAS THE HIGHEST GRADE OF REGULAR SCHOOL YOU COMPLETED? ______ ============================================================================== 13. ARE YOU CURRENTLY WORKING IN A COAL MINING JOB? 1 Y 2 N 14. WHAT WAS YOUR MAIN REASON FOR LEAVING COAL MINING? 1. LAID OFF __ 2. ANOTHER JOB __ 3. SICK __ 4. INJURED __ 5. OTHER: __ IF OTHER, REASON: _____________________________________________ 15. WHAT WAS THE LAST DATE OF YOUR WORK IN COAL MINING? ___/___ mm yy ============================================================================== B. OCCUPATIONAL HISTORY Record on lines the number of years in which the subject has worked in any of the below listed industries. Have you ever worked: 9. In any OTHER type of mine? 1 Yes 2 No No. years ____ 10. In a quarry? 1 Yes 2 No No. years ____ 11. In a foundry? 1 Yes 2 No No. years ____ 12. In a pottery? 1 Yes 2 No No. years ____ 13. In a cotton, flax, or hemp mill? 1 Yes 2 No No. years ____ 14. With asbestos? 1 Yes 2 No No. years ____ 15. In any other dusty jobs? 1 Yes 2 No No. years ____ Specify ____________________ TOTAL NUMBER OF YEARS ________ ============================================================================== C. SYMPTOMS I am going to ask you some questions, mainly about your chest. I would like you to answer "YES" or "NO" whenever possible. COUGH 1. Do you usually cough first thing in the morning 1 Yes 2 No (on getting up*) in the winter? Count a cough with first smoke or on first going out-of-doors. Exclude clearing throat or a single cough 2. Do you usually cough during the day (or at night*) 1 Yes 2 No in the winter? Ignore an occaisonal cough If "No" to both questions 1 and 2, go to question 4. If "Yes" to either question 1 or 2: 3. Do you cough like this on most days (or nights*) 1 Yes 2 No for as much as three months each year? 9 NA ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ *For individuals who work at night ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ PHLEGM 4. Do you usually bring up any phlegm from your chest 1 Yes 2 No first thing in the morning(on getting up*) in the winter? Count phlegm with first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm. 5. Do you usually bring up any phlegm from your chest 1 Yes 2 No during the day (or at night*) in the winter? Accept twice or more. If "No" to both questions 4 and 5, go to question 7. If "Yes" to either question 4 or 5: 6. Do you bring up phlegm like this on most days 1 Yes 2 No (or nights*) for as much as three months each year? 9 NA 7. In the past three years have you had a period of 1 Yes 2 No (increased**) cough and phelgm lasting for 3 weeks or more? If "No" to question 7, go to question 9. If "Yes" to question 7: 8. Have you had more than one such period? 1 Yes 2 No 9 NA 9. Have you ever coughed up blood? 1 Yes 2 No If "No" to question 9, go to question 11. If "Yes" to question 9: 10. Was this in the past year? 1 Yes 2 No 9 NA ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ *For individuals who work at night **For individuals who usually have phlegm ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ BREATHLESSNESS 11. Are you troubled by shortness of breath when 1 Yes 2 No hurrying on level ground or walking up a 0 disabled*** slight hill? If "No" or "Disabled" to question 11, go to question 14. If "Yes" to question 11: 12. Do you get short of breath walking with other 1 Yes 2 No people of your own age on level ground? 9 NA If "No" to question 12, go to question 14. If "Yes" to question 12: 13. Do you have to stop for breath when walking at 1 Yes 2 No your own pace on level ground? 9 NA ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ ***Disabled from walking by any conditions other than heart or lung disease ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ WHEEZING 14. Does your chest ever sound wheezing or whistling? 1 Yes 2 No If "No" to question 14, go to question 16. If "Yes" to question 14: 15. Do you get this most days -- or nights? 1 Yes 2 No 9 NA 16. Have you ever had attacks of shortness of breath 1 Yes 2 No with wheezing? If "No" to question 16, go to question 18. If "Yes" to question 16: 17. Is/Was your breathing absolutely normal between 1 Yes 2 No attacks? 9 NA WEATHER 18. Does the weather affect your chest? 1 Yes 2 No Only record "YES" if adverse weather definitely and regularly causes chest symptoms If "No" to question 18, go to question 21. If "Yes" to question 18: 19. Does the weather make you short of breath? 1 Yes 2 No 9 NA 20. What kind of weather? _____________________________________ 9 NA NASAL DRAINAGE 21. Do you usually have a stuffy nose or drainage 1 Yes 2 No at the back of your nose in the winter? 22. Do you have this in the summer? 1 Yes 2 No If "No" to both questions 21 and 22, go to question 24. If "Yes" to either question 21 or 22: 23. Do you have this on most days for as much as 1 Yes 2 No three months each year? 9 NA CHEST ILLNESSES 24. During the past three years have you had any chest 1 Yes 2 No illness which kept you from your usual activities for as much as a week? If "No" to question 24, go to question 27. If "Yes" to question 24: 25. Did you bring up more phlegm than usual in any 1 Yes 2 No of these illnesses? 9 NA If "No" to question 25, go to question 27. If "Yes" to question 25: 26. How many illnesses like this have you had in the ________ 9 NA past three years? HAVE YOU EVER HAD (Insert proper code, questions 27 through 36) Code: 0 = No; 1 = Once; 2 = Twice; etc... 9 = Nine or more times. Code ONLY 0 or 1 for questions 27, 28, 32, 33, 34, 35. 27. An injury or operation affecting your chest? 1 Yes 2 No 28. Heart trouble? 1 Yes 2 No 29. Bronchitis? 1 Yes 2 No 30. Pneumonia? 1 Yes 2 No 31. Pleurisy? 1 Yes 2 No 32. Pulmonary tuberculosis? 1 Yes 2 No 33. Bronchial asthma? 1 Yes 2 No 34. Emphysema? 1 Yes 2 No 35. Bronchiectasis? 1 Yes 2 No 36. Other chest trouble? 1 Yes 2 No 37. Have you ever been exposed regularly to 1 Yes 2 No irritating gas or chemical fumes? 38. Have you ever been exposed (within 30 feet) to 1 Yes 2 No the smoke of an underground cable fire? 9 NA If so, how many? ______ ============================================================================== D. TOBACCO SMOKING 1. Do you NOW smoke cigarettes? 1 Yes 2 No If "Yes" to question 1, go to question 4. If "No" to question 1: 2. Have you ever smoked cigarettes? 1 Yes 2 No 9 NA If "Yes" to question 2, go to question 4. If "No" to question 2: 3. Have you smoked at least as many as five packs of 1 Yes 2 No cigarettes, that is, 100 cigarettes during your 9 NA entire life? If "Yes" to question 3, go to question 4. If "No" to question 3, go to question 9. 4. How old were you when you started smoking cigarettes ______ regularly? (age-yrs) If an ex-cigarette smoker, ask: 5. How old were you when you last gave up smoking cigarettes? ______ (age-yrs) 5a. During the years that you smoked, did you ever 1 Yes 2 No quit for a year or more? If yes, how long? _______________ 6. How much do/did you smoke on the average? ________ cigs/day 7. Do/did you inhale the cigarette smoke? 1 Yes 2 No 8. What do/did you mostly smoke? 1=Filters __ 1=Regular __ 2=Non-filters __ 2=Kingsize __ 3=100 millimeter __ 9. Do you now smoke a pipe? 1 Yes 2 No If "Yes" to question 9, go to question 11. If "No" to question 9: 10. Have you ever smoked a pipe? 1 Yes 2 No 9 NA 11. How many bowls full a week do/did you smoke? _______ 12. Do you now smoke cigars? 1 Yes 2 No If "Yes" to question 12, go to question 14. If "No" to question 12: 13. Have you ever smoked cigars? 1 Yes 2 No 9 NA If "Yes" to question 13, go to question 14. If "No" to question 13, end interview. 14. How many cigars a week do/did you smoke? ______ ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Use "did" only for ex-smokers ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^