QUESTIONNAIRE: RESPIRATORY HEALTH IN COAL MINERS

STUDY ID   __________                          DATE: ___/___/___

INTERVIEWER NUMBER: ________             

When did interview take place?	 ______ 
A=After shift
B=Before shift
N=Neither B or A

A.IDENTIFICATION

1.	CURRENT ADDRESS:

STREET _________________________

SUBURB/AREA: ___________________

CODE  ________

CITY ____________________   PROVINCE  ____________________

2.	PHONE NUMBER: (_____) ______________

3.	IDENTITY NUMBER: __________________

4.	BIRTHDATE: ___/___/___                                        5.  AGE LAST BIRTHDAY ______
dd  mm  yy

6.	MARITAL STATUS:
1.  MARRIED  __
2.  WIDOWED  __
3.  DIVORCED  __
4.  SEPARATED  __
5.  NEVER MARRIED  __

8.	STANDING HEIGHT _____.___ (cms)    

9.	WEIGHT _____.____ (kgs)

B. SYMPTOMS
I am going to ask you some questions, mainly about your chest.  I would like you to answer "YES" or "NO" whenever possible.

Coding: 1=Yes (Y); 0=No (N); 9=Not applicable (NA)

COUGH

10.	Do you usually have a cough?
Y	N	

IF YES TO 10:
For how many years have you had this cough?          	___________
	Number years

PHLEGM

Count phlegm with first smoke or on first going out of doors.
Exclude phlegm from the nose.  Count swallowed phlegm.

11.	Do you usually bring up any phlegm/sputum/mucus from your chest 
      during the day (or at night) in the winter?
Y	N	

IF YES TO 11:
For how many years have you had trouble with phlegm?	_________ years

WHEEZING

12.	Does your chest ever sound wheezy or whistling:	
Y	N	
TB

13.	Have you had chest tuberculosis?
Y	N	

C. TOBACCO SMOKING

14.	Have you ever smoked cigarettes? 
NO means less than 20 packs of cigarettes in a lifetime or less than 1 cigarette a day for 1 year.
Y	N	
	
IF YES to 14:
	a. Do you now smoke cigarettes (as of 1 month ago)?	
Y	N	

	b. How old were you when you first started regular cigarette smoking?	____ Age 

c. If you have stopped smoking cigarettes completely,	____ Age stopped
   how old were you when you stopped?         
Mark N/A if still smoking                                                                 ___

d. How many cigarettes do you smoke per day now?    	___ Cigarettes/day

	e. In the past, how many did you smoke per day? 	___ Cigarettes/day
	f.  For how many years did you smoke this number?	___ years

E. OCCUPATIONAL HISTORY

COAL MINING
15.	Are you currently working in a coal mining job?  	
Y	N	

16.	Please list in the table below any job that you held for more than one (1) year in an underground coal mine. The job sites in the table are as follows: S= surface; CMF= continuous mine face; UNF= underground non-face; O= other – if OTHER, please state site)

JOB	JOB SITE	APPROX YEARS	
TITLE	S	CMF	UNF	OTHER	FROM	TO