Telephone CATI Questionnaire for Children's Clothing Ignition Questionnaire # ________ (1-4) Q.1 This questionnaire should be implemented on or before June 19, 2015. It contains 3 additional questions regarding the victim's recovery. Victims in these NEISS cases were reported to be under age 15, so a parent/guardian will be asked to complete the interview. Bold type indicates what should be said to the respondent. Instructions for the interviewer will be prefaced by "Interviewer:" and given in non-bold type. Do not read choices unless instructed to in the question. Never read the choice "Don't Know". Before contacting the victim, please review the NEISS emergency room information for the case and complete the next 3 questions in advance of making the call. Please note the victim's name and use it to identify the victim throughout the interview. Please maximize the Survey System window to view questions in the best formatting. Q.2 Interviewer: Complete before dialing. Enter Task Number (13 characters): __________________________ (5-17) Q.3 Interviewer: Complete before dialing. Enter Treatment Date, to be used in Introduction (Ex: October 10, 2012): __________________________________________________ (18-42) Q.4 Interviewer: Complete before dialing. Is Product Code 1313 - Fireworks coded for this NEISS case? (43) q 1 Yes q 2 No Q.5 Hello, may I speak with a parent or guardian of [victim's name]? Hello, I'm [interviewer name] from [contracting agency]. We are working with the U.S. Consumer Product Safety Commission or "CPSC" to learn more about fire and burn hazards involving children's clothing. I'd like to ask you a few questions about [victim's name]'s visit to the emergency room on [ANSWER TO Q. 3], so that we can prevent similar injuries in the future. Your participation is voluntary and your identity and answers will be kept completely confidential. Will you help us? (44) q 1 Yes - Continue q 2 No - Refusal [IF THE ANSWER IS 2, THEN SKIP TO QUESTION 115] Q.6 I understand that [victim's name] was treated in the emergency room for an injury caused by clothing that caught on fire, smoldered, or melted. Is that correct? (45) q 1 Yes - Continue q 2 No clothing involved q 3 No burning/fire involved [IF THE ANSWER IS 1, THEN SKIP TO QUESTION 8] Q.7 Can you tell me what actually happened? __________________________________________________________________________________ (46-545) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ [IF THE ANSWER TO QUESTION 6 IS 2 OR 3, THEN SKIP TO QUESTION 115] Q.8 What is your relationship to [victim's name] ? (546) q 1 Parent q 2 Other [IF THE ANSWER IS 1, THEN SKIP TO QUESTION 10] Q.9 Interviewer: Specify respondent's "Other" relationship to the victim. _________________________________________________________________________________ (547-596) Q.10 Did you witness the incident that prompted [victim's name] to go to the emergency room? (597) q 1 Yes q 2 No Q.11 Please tell me to the best of your knowledge how the incident happened and what injuries [victim's name] received. ________________________________________________________________________________ (598-1797) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Q.12 How old was the child when the incident occurred? Interviewer: Be sure to label the age given. Ex: 3 days old, 4 months old, 10 1/2 years old, almost 13 years old. ____________________________________________________________ (1798-1827) Q.13 What was the child's approximate height when the incident occurred? Interviewer: Be sure to label the measurement given. Ex: 3 1/2 ft., 25 in., 1 meter. ____________________________________________________________ (1828-1857) Q.14 About how much did child weigh when the incident occurred? Interviewer: Be sure to label the measurement given. Ex: 15 lbs., 13 kg. ____________________________________________________________ (1858-1887) Q.15 What was the extent of the injury? That is, how did the doctor characterize the burns suffered, in terms of percentage of body surface burned and whether the burns were 1st, 2nd, or 3rd degree? Did the doctor specify whether the burns were partial thickness or full thickness burns? _______________________________________________________________________________ (1888-2137) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Q.16 Did [victim's name] receive any additional treatment from a medical professional (such as a doctor or nurse) after treatment in the emergency room? (2138) q 1 Yes q 2 No q 3 Don't Know [IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 37] Q.17 What kind of additional treatment did [victim's name] receive? Interviewer: Enter all that apply. (2139-2144) q 1 Check up, cleaning, remove bandages, stitches q 2 Plastic or reconstructive surgery, skin grafts q 3 Other surgery q 4 Pressure garments q 5 Physical therapy q 6 Other q 7 Don't Know [IF THE ANSWER TO QUESTION 17 IS NOT 3, THEN SKIP TO QUESTION 19] Q.18 Interviewer: Specify "Other" surgery. _______________________________________________________________________________ (2145-2244) _______________________________________________________________________________ [IF THE ANSWER TO QUESTION 17 IS NOT 6, THEN SKIP TO QUESTION 20] Q.19 Interviewer: Specify "Other" treatment(s). _______________________________________________________________________________ (2245-2344) _______________________________________________________________________________ Q.20 Where did [victim's name] get this treatment? Interviewer: Read choices and enter all that apply. (2345-2351) q 1 Same hospital where [victim's name] went to the emergency room q 2 Another hospital q 3 Walk-in clinic q 4 Private physician's office q 5 HMO facility q 6 At home q 7 Other q 8 Don't Know [IF THE ANSWER TO QUESTION 20 IS NOT 2, THEN SKIP TO QUESTION 22] Q.21 What was the name of the "other hospital" where [victim's name] received treatment? _______________________________________________________________________________ (2352-2451) _______________________________________________________________________________ [IF THE ANSWER TO QUESTION 20 IS NOT 7, THEN SKIP TO QUESTION 23] Q.22 Please describe the "Other" location where [victim's name] received treatment. _______________________________________________________________________________ (2452-2551) _______________________________________________________________________________ Q.23 Was [victim's name] admitted to a hospital or other medical facility at any time due to this incident? (2552) q 1 Yes q 2 No q 3 Don't Know [IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 37] Q.24 How many hospitalizations has [victim's name] had due to this incident? Interviewer: Enter a number from 1 to 99. # Hospitalizations (1 - 99) ____ (2553-2554) Q.25 What was the name of the facility where [victim's name] was first admitted? _______________________________________________________________________________ (2555-2654) _______________________________________________________________________________ Q.26 What type of facility was it? Interviewer: Read choices. (2655) q 1 Burn hospital or hospital with a special burn ward q 2 Other hospital q 3 Rehabilitation/nursing home q 4 Other q 5 Don't Know [IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 28] Q.27 Please describe what "Other" kind of facility it was. _______________________________________________________________________________ (2656-2755) _______________________________________________________________________________ Q.28 How many nights did [victim's name] stay at that facility? Interviewer: Enter a number from 1 to 99. # Nights (1 - 99) ____ (2756-2757) Q.29 Is [victim's name] still in this facility? (2758) q 1 Yes q 2 No [IF THE ANSWER TO QUESTION 24 IS 1, THEN SKIP TO QUESTION 37] Q.30 Where was [victim's name's] next hospitalization? _______________________________________________________________________________