0920-24IK Respiratory Assessment Form

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Form Approved
OMB No. 0920-0020

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)

NIOSH
Coal Workers’ Health Surveillance Program
1000 Frederick Lane, M/S LB208
Morgantown, WV 26508

Miner Identification
Miner’s Name (Last)

(First)

(Middle)

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
2. Do you usually have a cough, apart from colds?
If YES, answer 2a and 2b.
2a. Do you cough on most days* for 3 or more months during
the year?
2b. About how many years have you had this cough?

No

Yes

No

Yes

Years

3. Do you usually bring up phlegm from your chest, apart from
colds? If YES, answer 3a and 3b.
3a. Do you bring up chest phlegm on most days* for 3 or more
months during the year?
3b. About how many years have you had phlegm like this?

No

Yes

No

Yes

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).
CDC/NIOSH 2.13 (E), Rev. 03/2021

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Respiratory Symptoms (continued)
4. In the last 12 months, have you had wheezing or whistling in your
chest at any time? If YES, answer 4a thru 4c.
4a. Mark one: Yes, I have wheezing only when I have a cold

No

Yes
Yes
Yes

OR

Yes, I have wheezing sometimes when I don’t
have a cold
4b. Does the wheezing always clear when you cough?

No

Yes

The same
4c. When you are away from the mine on days
off, is this wheezing or whistling (mark one)
5. In the past 12 months, have you had an episode of asthma or an
asthma attack?
5a. If YES, about how old were you when you first had an attack
of asthma?
6. Are you currently taking any medicine for your breathing?
(including inhalers, aerosols, or pills)
Inhalers
6a. If YES, mark what you are currently taking:

Worse

Better

No

Yes

7. Are you troubled by shortness of breath when hurrying on level
ground or walking up a slight hill? If YES, answer 7a.
7a. Do you have to walk slower than people of your age on level
ground because of shortness of breath? If YES, answer 7b.
7b. About how many years have you had this shortness of
breath?
Smoking History
8. 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 8a thru 8d.
8a. On average, for the entire time that you smoked, about how
many cigarettes did you smoke per day?
(1 pack = 20 cigarettes)
8b. About how old were you when you first started smoking
cigarettes regularly?
8c. Do you still smoke cigarettes?
If NO, about how old were you when you completely stopped
smoking?
Yes
If YES, would you like to quit smoking now?
8d. During the time you were a smoker, did you ever stop
smoking for 6 months or more?
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)
9. Do you use any other inhaled tobacco or nicotine products (pipes,
cigars, electronic cigarettes, e-cigarettes etc.)?
Every Day
9a. If YES, do you use them (mark one)
* = Most days means 4 or more days each week.

Age
No

Yes

Aerosols

Pills

No

Yes

No

Yes

Years

No

Yes

Cigarettes per Day

Age
No

Yes

Age
Maybe

No

No

Yes
Years

No

Yes

Most Days

Some Days

CDC/NIOSH 2.13 Rev. 01/2015

CDC/NIOSH 2.13 (E), Rev. 03/2021

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