Form assigned Att 2 - Data collection Instrument for ICARIS-2 (Phase-2

OMB Attachment #2 – Data collection instrument

Form Approved: ____________

OMB Number: ____________

Expiration Date: ____________

	RESPONDENT ID
	DATE
	INTERVIEWER
	TOTAL TIME

[Amended Survey, Protocol #2900, submitted September, 2005 to IRB]

[submitted July, 2006 to OMB]

SECOND INJURY CONTROL AND

RISK SURVEY

ICARIS-2 (Phase-2)

Final English Version

Prepared for:

National Center for Injury Prevention and Control

Prepared by:

Battelle

Centers for Public Health Research and Evaluation

Baltimore, Maryland

Initially submitted December 2002

Modified April 2003 based on reviewers comments

Modified May 2003 based on IRB-G review comments

Modified August 2005 based on results of cognitive testing

Modified April 2006 based on NCIPC-OMB review comments

Public reporting burden of this collection of information varies from 13 to 28 minutes with an estimated average of 15 minutes 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 thus burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS-D74, Atlanta, Georgia 30333; ATTN: PRA (09020-XXXX).

/home/ec2-user/sec/disk/omb/icr/200609-0920-003/doc/437801ICARIS-2 (Phase-2) Telephone Screener Script

I. INTRODUCTION:

Hello, I’m ________________, calling on behalf of the Centers for Disease Control and Prevention or CDC. CDC is a government agency that works to safeguard and improve the health of the public through scientific research, including studies of disease outbreaks and injury prevention. We are conducting a nationwide research study to learn more about how to prevent injuries.

SC1. Is this a business, a residence, a dormitory or some other type of dwelling? (IF OTHER, PROBE TO DETERMINE IF RESIDENCE OR NOT) (1=Business, 2=Residence, 3=Dormitory, 4=Group quarters or vacation rental)

IF BUSINESS, DORM OR GROUP QUARTERS – That’s all I need to know. Goodbye. COMPUTER WILL CODE AS BUSINESS OR GROUP QUARTERS AND BRING UP NEXT NUMBER TO DIAL

IF RESIDENCE, CONTINUE

INTERVIEWER CODE WHETHER TO CONTINUE INTERVIEW IN ENGLISH OR SPANISH

II. SCREENING:

I need to speak to a member of this household who is 18 years of age or older. Is that you?

YES If speaking to an ADULT HH MEMBER, continue (COMPUTER WILL ASK YOU TO RECORD GENDER OF ADULT TO WHOM YOU ARE SPEAKING – IF GENDER IS UNCLEAR ASK: And are you a male or a female? ALSO RECORD THAT HOUSEHOLD CONTAINS AT LEAST ONE ADULT)

no If a new respondent comes to the phone, repeat PARAGRAPHS i AND II and continue

(COMPUTER WILL ASK YOU TO RECORD GENDER OF ADULT TO WHOM YOU ARE SPEAKING SPEAKING – IF GENDER IS UNCLEAR ASK: And are you a male or a female? ALSO RECORD THAT HOUSEHOLD CONTAINS AT LEAST ONE ADULT)

no If adult hh member is not available ask: When could I call back to reach an adult member of this household? GO TO APPOINTMENT TAB AND RECORD DATE AND TIME OF SUGGESTED CALL BACK. ALSO RECORD THAT HOUSEHOLD CONTAINS AT LEAST ONE ADULT

no ALL HOUSEHOLD MEMBERS ARE LESS THEN 18 YEARS OLD: That’s all I need to know. Goodbye. RECORD THAT HOUSEHOLD CONTAINS NO ADULTS

III. INCENTIVE:

I need to randomly select an adult to interview. In appreciation for their time and effort, the person I select will be sent a phone card after they complete the interview. The card will provide 100 minutes of pre-paid long distance phone service, or if they like we can donate $5.00 to the United Way instead.

IF PERSON REFUSES PRIOR TO OR DURING SCREENING BEFORE ELIGIBLE RESPONDENT IS IDENTIFIED, SELECT A REFUSAL TAB AND CODE REFUSED SCREENING. POSSIBLE CODES WILL DIFFER DEPENDING ON WHTHER OR NOT WE KNOW THERE IS AN ADULT IN THE HOUSHEOLD.

SC2. How many persons live in this household? Include yourself and also include children in answering. NOTE: IF R VOLUNTEERS THAT A HOUSEHOLD MEMBER IS LIVING ELSWHERE OR ON LONG TERM DEPLOYMENT

FOR THE ENTIRE FIELD PERIOD, DO NOT COUNT THAT PERSON IN THE HOUSHOLD TOTAL

RECORD NUMBER [2-digits, 98=DK, 99=RF]

SC3. How many adults live in this household? An adult is 18 years of age or older?

RECORD NUMBER [2-digits, 98=DK, 99=RF]

SC4. How many of these adults are men?

RECORD NUMBER [2-digits, 98=DK, 99=RF]

IF ANY OF SC2, SC3 OR SC4 ARE DK OR RF, WE DO NOT KNOW THE NUMBER OF ADULTS IN THE HOUSEHOLD AND WE NEED TO CODE THIS NUMBER AS REFUSED SCREENING.

IF SC3 = 1 (YOU ARE SPEAKING TO THE ONLY ADULT IN A ONE ADULT HOUSEHOLD), READ: You are eligible to participate in the study. GO TO PARAGRAPH IV

SC5. Are any of the people who live in this household related to each other?

RECORD ANSWER [1=Yes, 2=No, 8=DK, 9=RF]

BASED ON ANSWERS TO SC3 AND SC4, THE COMPUTER WILL PICK AN APPROPRIATE GENDER AND ADULT TO INTERVIEW.

IF SPEAKING TO THE ONLY ADULT OF THE SELECTED GENDER, READ: You are eligible to participate in the study. GO TO PARAGRAPH IV

IF SELECTED GENDER IS OPPOSITE OF RESPONDENT, AND ONLY ONE PERSON OF SELECTED GENDER IS IN HOUSEHOLD, READ: May I please speak with the adult (male/ female) in the household?

If a new respondent comes to the phone, repeat PARAGRAPHS i AND III and continue WITH PARAGRAPH IV

IF OTHER ADULT IS NOT AVAILABLE TO COME TO THE PHONE, ASK: When could I call back to reach (him/her)? Whom should I ask for when I call back? GO TO APPOINTMENT TAB AND RECORD FIRST NAME OF RESPONDENT AND DATE AND TIME OF CALL BACK. IF SELECTED RESPONDENT NEEDS TO BE CALLED AT ANOTHER NUMBER (E.G., A DORM NUMBER, CELL PHONE OR ON ANOTHER LINE) RECORD NUMBER AND REASON AS A NOTE. IF SELECTED RESPONDENT IS AWAY AND CANNOT BE REACHED AT ANOTHER NUMBER (E.G., IN A DORM, IN THE HOSPITAL, OR ON VACATION) AND NEEDS TO BE CALLED LATER, RECORD REASON AND EXPECTED DATE OF RETURN IN A NOTE.

IF HOUSEHOLD HAS MORE THAN ONE ADULT OF SELECTED GENDER, READ: May I please speak to the (oldest, second youngest, youngest) adult living in this household?

IF SPEAKING TO SELECTED RESPONDENT, READ: You are eligible to participate in the study. GO TO PARAGRAPH IV

If a new respondent comes to the phone, repeat PARAGRAPHS i AND III and continue WITH PARAGRAPH IV

IF OTHER ADULT IS NOT AVAILABLE ASK: When could I call back to reach (him/her)? Whom should I ask for when I call back? GO TO APPOINTMENT TAB AND RECORD FIRST NAME OF RESPONDENT AND DATE AND TIME OF CALL BACK. IF SELECTED RESPONDENT NEEDS TO BE CALLED AT ANOTHER NUMBER (E.G., A DORM NUMBER, CELL PHONE OR ON ANOTHER LINE) RECORD NUMBER AND REASON AS A NOTE. IF SELECTED RESPONDENT IS AWAY AND CANNOT BE REACHED AT ANOTHER NUMBER (E.G., IN A DORM, IN THE HOSPITAL, OR ON VACATION) AND NEEDS TO BE CALLED LATER, RECORD REASON AND EXPECTED DATE OF RETURN IN A NOTE.

(PROGRAMMER: BEGIN RECORDING SCTIME HERE)

IV. PARTICIPATION:

Injury research covers a wide range of topics in the areas of both unintentional and intentional injury. This particular survey collects information on a variety of topics including child welfare and supervision, firearm storage, injuries and disabilities, difficulties with mobility and transportation, and suicide; all of which will help us better understand ones’ risk for injury. Participation in this study is voluntary but we’d very much appreciate your help. All the information given us will be kept private. We will not ask for any personal information that identifies you. Please use first names only if you need to refer to a family member in answering a question.

RECORD ONLY FIRST NAMES OR NICKNAMES THROUGHOUT SCREENER AND QUESTIONNAIRE. DO NOT INCLUDE ANY IDENTIFYING INFORMATION IN THE CATI INSTRUMENT.

Some questions may make you uncomfortable. You may refuse to answer any question and you may end the interview at any time. By answering this survey, you can help us learn how to prevent injuries. On average, the interview takes about 15 minutes.

Do you have any questions about this study or your rights as a research subject in this survey?

ANSWER FROM FAQs IF POSSIBLE.

IF NEEDED READ: If you have questions about your rights as a participant in this research study, please contact the office of CDC’s Deputy Associate Director for Science at 1-800-584-8814. Please leave a brief message including your name, telephone number, and mention that you are calling in reference to CDC Protocol #2900. Someone will return your call as soon as possible. For questions or information about other aspects of the survey, call Chester Pogostin at 1-770-488-4805.

My supervisor may monitor this call for quality purposes.

IF IDENTIFIED RESPONDENT REFUSES TO PARTICIPATE, SELECT A REFUSAL TAB AND CODE REFUSED INTERVIEW

Let’s start the interview now.

IF RESPONDENT INDICATES TIMING IS INCONVENIENT ASK: When would be a good time to call back? Whom should I ask for when I call back? GO TO APPOINTMENT TAB AND RECORD FIRST NAME OF RESPONDENT AND DATE AND TIME OF CALL BACK

(PROGRAMMER: STOP RECORDING SCTIME HERE)

			START TIME :
MODULE 1: DEMOGRAPHICS AND HOME
I would like to ask you for some general background information. If at any time you do not understand a question or words please ask for clarification.
DH1.	SEX OF RESPONDENT IS CODED FROM SCREENER.		MALE 1 FEMALE 2
DH2Mon. (DH2Day) DH2Yr.	What year were you born?		DOB (SKIP TO RESPAGE) DK 98 98 9998 RF 99 99 9999
DH2A.	Are you younger than 65 years old?		YES 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
	PROGRAMMER NOTE: IF DH2A = 1 OR 8 OR 9, FOLLOW SKIPS FOR R BEING < 65. IF DH2A = 2, FOLLOW SKIPS FOR R BEING > 65.
RespAge	CALCULATE AGE OF RESPONDENT.		AGE DK 998 RF 999
DH3.	What is the highest grade or year of school you have completed? READ ANSWERS 1-6 IF NEEDED		EIGHTH GRADE OR LESS 01 SOME HIGH SCHOOL 02 HIGH SCHOOL GRAD OR GED CERTIFICATE 03 SOME POST HIGH SCHOOL 04 COLLEGE GRADUATE (ASSOCIATE OR BACHELORS) 05 POST GRADUATE EDUCATION OR DEGREE 06 SOMETHING ELSE (SPECIFY) 07 DK 98 RF 99
DH3Code	SPECIFY: ______________________________
	EDITOR NOTE: USE CODES 8-95, 98 99 ONLY IN DH3Code
	IF SC2 = 1 OR IF DH3 = 06, THEN FILL DH4 WITH DH3 ANSWER AND SKIP TO DH5
DH4.	What is the highest grade or year of school that anyone in your current household has completed? READ ANSWERS 1-6 IF NEEDED		EIGHTH GRADE OR LESS 01 SOME HIGH SCHOOL 02 HIGH SCHOOL GRAD OR GED CERTIFICATE 03 SOME POST HIGH SCHOOL 04 COLLEGE GRADUATE (ASSOCIATE OR BACHELORS) 05 POST GRADUATE EDUCATION OR DEGREE 06 SOMETHING ELSE (SPECIFY) 07 DK 98 RF 99
DH4Code	SPECIFY: ______________________________
	EDITOR NOTE: USE CODES 8-95, 98 99 ONLY IN DH4Code
DH5.	Are you currently (READ ANSWERS)?		Employed or self-employed full-time 01 Employed or self-employed part-time 02 Homemaker or caregiver 03 Out of work or unable to work 04 Student 05 Student and employed 06 Retired 07 DK 98 RF 99
DH6	Do you consider yourself of Hispanic/Latino origin such as Mexican, Latin American, Puerto Rican, or Cuban?		YES 1 NO 2 DK 8 RF 9
DH7	What is your race? Please select one or more of the following. READ ANSWERS AND CODE ALL THAT APPLY		American Indian or Alaska Native 1 Asian 2 Black or African American 3 Native Hawaiian or Other Pacific Islander 4 White 5 RF 9
	PROGRAMMER NOTE: RE-CODE INTO DH7_01 … DH7_05 WHERE 1=YES AND 2=NO
DH8.	Are you currently (READ ANSWERS)?		Married 1 Divorced 2 Widowed 3 Separated 4 Never married 5 A member of an unmarried couple 6 DK 8 RF 9
DH9	Which of the following best describes the building you live in? READ ANSWERS. NOTE: DORMS OR NURSING HOMES ARE NOT ELIGIBLE – END INTERVIEW.		A one-family house not attached to any other house 01 A one-family house attached to one or more homes 02 A mobile home or trailer 03 A building with only 2 apartments 04 A building with just 3 to 4 apartments 05 A building with 5 or more apartments 06 Or something else 07 DK………………………………………………………………….98 RF………………………………………………………………….99
DH10.	Is the place in which you live (READ ANSWERS)?		Owned by you or someone else in the home 1 Rented by you or someone else in the home 2 Military housing 3 Or something else (SPECIFY) 4 DK 8 RF 9
DH10 Code	SPECIFY: (1) WHO OWNS THE HOME OR APARTMENT UNIT, (2) WHETHER THE OWNER LIVES IN THIS HOME, (3) WHETHER THE PEOPLE LIVING HERE PAY ANY RENT TO THE OWNERS, AND (4) ANY OTHER DETAILS: .
	EDITOR NOTE: USE CODES 05-95 ONLY IN DH10CODE.
DH11	Does more than one telephone number ring in this residence? Do not include cell phones or telephone lines that are only answered by a computer or other machine, or telephone lines used only for business purposes.		YES 1 NO (SKIP TO MOBL1) 2 DK (SKIP TO MOBL1) 8 RF (SKIP TO MOBL1) 9
DH12.	Including the number I just dialed, how many different numbers ring in this home?		TOTAL TELEPHONE NUMBERS DK………………………………………………………………….98 RF………………………………………………………………….99 N/A (SKIP) 97
	IF DH12 < 4 OR = 98 OR 99, SKIP TO MOBL1.
(A)	Are these (DH12) lines actually different phone numbers? We are not counting multiple phones for the same telephone number		YES 1 NO (RETURN TO DH12) 2 DK (RETURN TO DH12) 8 RF (RETURN TO DH12) 9 N/A (SKIP) 7

MODULE 2: OLDER ADULT MOBILITY

IF RESPAGE < 65 OR = 98 OR = 99, SKIP TO SUPR1.

We would like to ask you a few questions about how much you drive and how much you walk.

MOBL1.

About how many miles did you drive during the past 12 months, that is since (MONTH, YEAR)? IF R ANSWERS “NONE” OR “DID NOT DRIVE IN PAST 12 MONTHS,” PROMPT AS NEEDED: Is that because you don’t have a driver’s license? IF LESS THAN 500 MILES, ROUND DOWN TO THE NEAREST THOUSAND. IF 500 MILES OR MORE, ROUND UP TO NEAREST THOUSAND.

NONE/ DID NOT DRIVE
PAST 12 MONTHS (SKIP TO MOBL3) 000

DROVE LESS THAN 1,000 MILES 995

NUMBER OF MILES

IN THOUSANDS

NO DRIVERS LICENSE (SKIP TO MOBL3) 996

DK 998

RF 999

N/A (SKIP) 997

PROGRAMMER NOTE: CONFIRM NUMBER OF MILES MULTIPLIED BY 1,000.

MOBL2.

For the following driving situations, please respond with often, sometimes or never.

Often

Some

times

Never

DK

RF

N/A (SKIP)

a. Do you drive at night? Would you say often, sometimes or never?

1

2

3

8

9

7

b. (Do you drive) on long trips, that is more than 50 miles one way? (Would you say often, sometimes or never?)

1

2

3

8

9

7

c. (Do you drive) in heavy traffic? (Would you say often, sometimes or never?)

1

2

3

8

9

7

d. (Do you drive) in bad weather? (PROMPT: including rain, sleet, snow) (Would you say often, sometimes or never?)

1

2

3

8

9

7

MOBL3.

Are you able to walk outside the home for at least 10 minutes, or a quarter mile, without resting?

IF “R” SAYS UNABLE DUE TO A TEMPORARY MEDICAL CONDITION, PROMPT: Are you normally able to walk that far?

YES 1

NO 2

DK 8

RF 9

N/A (SKIP) 7

MOBL4.

If you wanted to visit a friend, say no more than 3 or 4 blocks away, would you walk, (IF MOBL1 NE 0,996: drive), get a ride, or get there some other way? IF “R” SAYS ANSWER DEPENDS ON WEATHER, PROMPT: During a day with good weather.

WALK 1

DRIVE 2

GET A RIDE 3

OTHER (SPECIFY) 4

DK 98

RF 99

N/A (SKIP) 97

MOBL4CD

SPECIFY:

EDITOR NOTE: USE CODES 5 TO 95, 98, 99 ONLY IN MOBL4CD.

MOBL5.

About how many minutes do you walk outside the home each week? IF R SAYS I DO NOT WALK, PROMPT: Can you no longer walk or is this a temporary condition? IF R SAYS UNABLE DUE TO A TEMPORARY MEDICAL CONDITION, PROMPT: When you do walk, about how many minutes do you walk outside the home each week? IF R SAYS IT VARIES FROM WEEK TO WEEK, PROMPT: Just give an average, or the usual amount of time. CONVERT HOURS TO MINUTES. 1 HOUR = 60 MINUTES, ½ HOUR = 30 MINUTES, ¼ HOUR = 15 MINUTES

MINUTES

DON’T WALK/DON’T WALK OUTSIDE 000
DK 998

RF 999

N/A (SKIP) 997

MOBL6.

Do you limit how much you walk outside your home because you are worried about falling?

YES 1

NO 2

DK 8

RF 9

N/A (SKIP) 7

MOBL7.

In the past three months, that is since (MONTH AND DATE), have you fallen?

YES 1

NO 2

DK 8

RF 9

N/A (SKIP) 7

MOBL8.

Do you currently use an assistive device like a cane or walker when you go outdoors?

YES 1

NO 2

DK 8

RF 9

N/A (SKIP) 7

MOBL9.

At what age (do you think you will stop/did you stop) driving?

AGE BELOW 95

AGE 95 OR OLDER 95

GAVE REASON, NOT AGE (SPECIFY) 01

WILL NEVER STOP DRIVING 00

NEVER DROVE 96

DK 98

RF 99

N/A (SKIP) 97

MOBL9CD

SPECIFY:
PROGRAMMER NOTE: USE “did you stop” WHEN MOBL1 = 000 OR 996.
EDITOR NOTE: USE CODES 2 TO 15, 98, 99 ONLY IN MOBL9CD.

MODULE 3: CHILD SUPERVISION
We would like to ask you a few questions about how children of all ages spend their time in and around the home.
SUPR1.	How many children under 18 live in your household, all or most of the year?						NUMBER OF CHILDREN NONE (SKIP TO SUPR5) 00 DK (SKIP TO SUPR5) 98 RF (SKIP TO SUPR5) 99
(SUPR2).	How old is the (youngest/next youngest) child? RECORD 00 IF LESS THAN 1 YEAR OLD. ROUND DOWN.						(SUPR3). Is this child a boy or a girl?
		AGE	DK	RF	N/A( SKIP)		BOY	GIRL	DK	RF	NA(SKIP)
	CHILD 1		98	99	97		1	2	8	9	7
	CHILD 2		98	99	97		1	2	8	9	7
	CHILD 3		98	99	97		1	2	8	9	7
	CHILD 4		98	99	97		1	2	8	9	7
	CHILD 5		98	99	97		1	2	8	9	7
	CHILD 6		98	99	97		1	2	8	9	7
	CHILD 7		98	99	97		1	2	8	9	7
	CHILD 8		98	99	97		1	2	8	9	7
	CHILD 9		98	99	97		1	2	8	9	7
	CHILD 10		98	99	97		1	2	8	9	7
	PROGRAMMER NOTE: THE VARIABLES SUPR2 AND SUPR3 DO NOT ACTUALLY APPEAR ON THE DATA SET. INSTEAD, VARIABLES SUPR2_01 - SUPR2_10, SUPR3_01 – SUPR3_10 WILL APPEAR.
SUPR4	Are you ever responsible for looking after the (child who lives/children who live) in your home?						YES (SKIP TO SUPR6) 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
SUPR5	Have you ever been a caretaker for a child under 15 years old?						YES 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
	IF NO CHILDREN AGED 1-10, SKIP TO SUPR10
The next four questions will ask about the child in your home who is age (YOUNGEST AGE BETWEEN 1-10)
SUPR6	Does (he/she) ever play outside for more than 10 minutes without an adult outside?						YES 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
SUPR7	Does (he/she) ever play in a room in the house for more than 10 minutes without an adult in the room?						YES 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
SUPR8	Is (he/she) ever in the bathtub with another child without an adult present in the room, even if just for a few seconds?						YES 1 NO 2 NO BATHTUB 6 DK 8 RF 9 N/A (SKIP) 7
	IF SUPR8 = 6, CODE SUPR9 = 6 AND SKIP TO SUPR10.
SUPR9.	Is (he/she) ever in the bathtub alone? That is, without anyone else in the room, even if just for a few seconds?						YES 1 NO 2 NO BATHTUB 6 DK 8 RF 9 N/A (SKIP) 7
SUPR10	Thinking now about a typical child, what do you think is the minimum age a child can safely be left alone in their house without an adult? (PROMPT: There is not a right or wrong answer to this question. We just want you to think about the average child, and what the minimum age might be that they can safely be left alone in their house without an adult.) ROUND DOWN.						YEARS DK ……………………………………………….…. 98 RF 99
SUPR11	What do you think is the minimum age a child can safely take a bath without an adult in the room? Again, we are asking you to think about the typical child. (PROMPT: There is not a right or wrong answer to this question. We just want you to think about the average child, and what the minimum age might be that they can safely take a bath without an adult in the room.) ROUND DOWN.						YEARS DK ……………………………………………….…. 98 RF 99
SUPR12	What do you think is the minimum age a child can safely ride a bike in a low traffic area without an adult outside? (We are asking you to think about the typical child.) (PROMPT: There is not a right or wrong answer to this question. We just want you to think about the average child, and what the minimum age might be that they can safely ride a bike in a low traffic area without an adult outside.) ROUND DOWN.						YEARS DK ……………………………………………….…. 98 RF 99

MODULE 4: INJURY AND DISABILITY
We are now going to ask questions about injuries you may have recently experienced. (PROMPT: Such as a car crash, falls, sports injuries, and assaults. ADDITIONAL PROMPT: The term injury does not include cases of tumors, infection, disease, stroke or aneurysm.)
DIS1.	During the past 12 months, that is since (MONTH, YEAR) were you treated in an Emergency Room or Urgent Care Center because of an injury?		YES 1 NO (SKIP TO HD1) 2 DK (SKIP TO HD1) 8 RF (SKIP TO HD1) 9
DIS2.	How many times have you been treated in the past 12 months? Do not include multiple ER visits for the same injury or multiple visits for different injuries from the same incident.		NUMBER OF ER VISITS DK 98 RF 99 N/A (SKIP) …………………………………………...……………97
	PROGRAMMER NOTE: ASK DIS3A – DIS11A FOR MOST RECENT INCIDENT. REPEAT DIS3A – DIS11A FOR SECOND INCIDENT USING QUESTIONS DIS3B – DIS11B. REPEAT DIS3A – DIS11A FOR THIRD INCIDENT USING QUESTIONS DIS3C – DIS11C. REPEAT DIS3A – DIS11A FOR FOURTH INCIDENT USING QUESTIONS DIS3D – DIS11D.
DIS3A.	IF DIS2>1: (Beginning with the most recent/Thinking about the 2nd, 3rd, 4th) injury producing incident for which you were treated at an Emergency Room… Were you admitted to the hospital for one or more nights?		YES 1 NO (CODE DIS4A = 0) 2 NOT TREATED FOR ANOTHER INJURY IN THE ER………… .. (SKIP TO HD1) 6 DK (SKIP TO DIS5A) 8 RF (SKIP TO DIS5A) 9 N/A (SKIP) 7
	PROGRAMMER NOTE: ANSWER 6 ONLY APPLIES TO DIS3B, DIS3C AND DIS3D.
DIS4A.	Altogether, how many nights did you stay in the hospital?		NUMBER OF NIGHTS DK 98 RF 99 N/A (SKIP) 97
DIS5A.	What injuries did you sustain? Did you have (READ CATEGORIES)?		YES	NO	DK	RF	N/A (SKIP)
	1. a head or brain injury (PROMPT: skull fracture, concussion)		1	2	8	9	7
	2. a spinal cord injury, broken neck or back		1	2	8	9	7
	3. any other broken bones, dislocated joints		1	2	8	9	7
	4. any burns		1	2	8	9	7
	5. any internal injuries		1	2	8	9	7
	6. any cuts or lacerations		1	2	8	9	7
	7. any sprains or strains		1	2	8	9	7
	8. something else (SPECIFY)		1	2	8	9	7
DIS5ACD	SPECIFY:
	EDITOR NOTE: USE CODES 1-95, 97=N/A(SKIP). 98=DK, 99=RF ONLY IN DIS5ACD.

DIS6A.		What was the cause of (this injury/these injuries), a motor vehicle crash, sports or recreation related, a fall not related to sports or recreation, an assault, or something else?					MOTOR VEHICLE CRASH 1 SPORTS OR RECREATION 2 FALL, NOT SPORTS OR RECREATION RELATED 3 ASSAULT 4 OTHER (SPECIFY) 5 DK 98 RF 99 N/A (SKIP) 97
DIS6ACD		SPECIFY:
		EDITOR NOTE: USE CODES 6-95, 97=N/A(SKIP), 98=DK, 99=RF ONLY IN DIS5ACD.
DIS7AU		As a result of your (injury/injuries), how long did you have to take time off from work, school, or household responsibilities? CODE UNIT AND THEN NUMBER. FOR NONE RECORD 0 DAYS.					ANSWER IN DAYS 1 ANSWER IN WEEKS 2 ANSWER IN MONTHS 3 DK (DIS7A = 998) 8 RF (DIS7A = 999) 9 N/A (SKIP) 7
DIS7A.							NUMBER DK 998 RF 999 N/A (SKIP) 997
DIS8A.		As a result of (this injury/these injuries) did you ever have or do you currently have any physical limitations, memory or concentration problems?					YES 1 NO (SKIP TO HD1) 2 DK (SKIP TO HD1) 8 RF (SKIP TO HD1) 9 N/A (SKIP) 7
		DIS9A.					DIS10A.			DIS11AU, DIS11A.
DIS9A, DIS10A, DIS11AU, DIS11A		Have you experienced any limitation or difficulty with (READ OPTIONS)? 8=DK, 9=RF					Does the problem still exist? 8=DK, 9=RF			IF DIS10A = 2, READ: For how long did the problem last? ELSE, For how long have you had this problem? CODE UNIT, THEN NUMBER.
			YES (ASK DIS10A)	NO (SKIP TO NEXT OPTION)	N/A (SKIP)		YES	NO	N/A (SKIP)
	1. bathing, dressing, getting in and out of bed, using the toilet, or eating		1	2	7		1	2	7	ANSWER IN DAYS 1 ANSWER IN WEEKS 2 ANSWER IN MONTHS 3 DK (DIS11A = 998) 8 RF (DIS11A = 999) 9 N/A (SKIP) 7 NUMBER N/A (SKIP) 997
	2. preparing meals, managing money, shopping, doing housework, traveling, or taking medicine		1	2	7		1	2	7	ANSWER IN DAYS 1 ANSWER IN WEEKS 2 ANSWER IN MONTHS 3 DK (DIS11A = 998) 8 RF (DIS11A = 999) 9 N/A (SKIP) 7 NUMBER N/A (SKIP) 997
	3. walking		1	2	7		1	2	7	ANSWER IN DAYS 1 ANSWER IN WEEKS 2 ANSWER IN MONTHS 3 DK (DIS11A = 998) 8 RF (DIS11A = 999) 9 N/A (SKIP) 7 NUMBER N/A (SKIP) 997

	4. As a result of (this injury/these injuries) have you experienced any limitation or difficulty with remembering things or concentrating?	1	2	7	1	2	7	ANSWER IN DAYS 1 ANSWER IN WEEKS 2 ANSWER IN MONTHS 3 DK (DIS11A = 998) 8 RF (DIS11A = 999) 9 N/A (SKIP) 7 NUMBER N/A (SKIP) 997

MODULE 5: TBI INCIDENCE
The following questions are about head injuries you or someone in your household may have experienced over the past year. Please do not include injuries to the face.
	IF NONE OF DIS5A1 AND DIS5B1 AND DIS5C1 AND DIS5D1=1, SKIP TO HD1W.
HD1.	IF ONLY 1 OF DIS5A1 = 1 OR DIS5B1 = 1 OR DIS5C1 = 1 OR DIS5D1 = 1, READ: You just mentioned a head injury in which you were treated in an Emergency Room. Were you knocked out or unconscious, did you suffer a concussion or memory loss, or were you dazed or confused as a result of this head injury?		YES (SKIP TO HD1X) 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
	IF > 1 OF DIS5A1 = 1 AND DIS5B1 = 1 AND DIS5C1 = 1 AND DIS5D1 = 1, READ: You just mentioned (two/several) incidents which resulted in head injuries for which you were treated in an Emergency Room. Were you knocked out or unconscious, did you suffer a concussion or memory loss, or were you dazed or confused as a result of any of these injuries?
HD1W.	During the past 12 months, that is since (MONTH, YEAR), have you experienced (a/another) head injury or blow to the head in which you were knocked out or unconscious, suffered a concussion or memory loss, or were dazed or confused (but did not result in an ER visit)? NOTE: IF RESPONDENT OFFERS THAT S/HE HAS HAD MULTIPLE HEAD INJURIES, COLLECT INFORMATION ON THE MOST SEVERE AS DETERMINED BY THE RESPONDENT. (PROMTP: By most severe, I mean the one that required the most medical attention or had the longest loss of consciousness.)		YES………………………………………………………………….1 NO (SKIP TO HD7) 2 DK (SKIP TO HD7) 8 RF (SKIP TO HD7) 9 N/A (SKIP) …….. 7
	PROGRAMMER NOTE: IF NONE OF DIS5A1 AND DIS5B1 AND DIS5C1 AND DIS5D1 = 1, SKIP TO HD2A. IF HD1 = 2,8,OR 9, SKIP TO HD2A. IF ONLY DIS5A1 = 1, CODE HD1X = 1. IF ONLY DIS5B1 = 1, CODE HD1X = 2. IF ONLY DIS5C1 = 1, CODE HD1X = 3. IF ONLY DIS5D1 = 1, CODE HD1X = 4.
HD1X.	Which of the previously reported injury producing incidents resulted in the most severe head injury? By most severe, I mean the one that required the most medical attention or had the longest loss of consciousness.		FIRST 1 SECOND 2 THIRD 3 FOURTH 4 DK 8 RF 9 N/A (SKIP) 7
	PROGRAMMER NOTE: FOR ALL DIS5 = 1, DISPLAY CORRESPONDING DIS6, DIS7 AND DIS7U
	ASK HD2A – HD6A FOR RESPONDENT’S HEAD INJURY.

HD2A.	For how long (were you/was the AGE AND GENDER PERSON #1/ #2/ #3/ #4) knocked out or unconscious? IF R ANSWERS DK, PROBE: Is this because you don’t know if (you/the AGE AND GENDER PERSON #1/#2/ #3/#4) (were/was) unconscious or you don’t know for how long?		0 MINUTES (NOT KNOCKED OUT/UNCONSCIOUS) 1 1-5 MINUTES 2 6-30 MINUTES 3 31 MINUTES – 24 HOURS 4 >24 HOURS 5 UNCONSCIOUS and UNSURE HOW LONG 6 DK IF UNCONSCIOUS 98 RF 99 N/A (SKIP) 97
HD3A.	Did (you/the AGE AND GENDER PERSON #1/ #2/ #3/ #4) suffer memory loss for events after the head injury incident?		YES 1 NO 2 DK 8 RF 9 N/A (SKIP) 7
	PROGRAMMER NOTE: FOR A SERIES ONLY … IF HD1X = 7, ASK HD4A – HD6A, THEN ASK HD7. IF HD1X = 1 AND DIS3A = 1, CODE HD4A = 5, HD5A = 7, CODE DIS6A INTO HD6A AND ASK HD7. IF HD1X = 1 AND DIS3A > 1, CODE HD4A = 4, HD5A = 7, CODE DIS6A INTO HD6A AND ASK HD7. IF HD1X = 2 AND DIS3B = 1, CODE HD4A = 5, HD5A = 7, CODE DIS6B INTO HD6A AND ASK HD7. IF HD1X = 2 AND DIS3B > 1, CODE HD4A = 4, HD5A = 7, CODE DIS6B INTO HD6A AND ASK HD7. IF HD1X = 3 AND DIS3C = 1, CODE HD4A = 5, HD5A = 7, CODE DIS6C INTO HD6A AND ASK HD7. IF HD1X = 3 AND DIS3C > 1, CODE HD4A = 4, HD5A = 7, CODE DIS6C INTO HD6A AND ASK HD7. IF HD1X = 4 AND DIS3D = 1, CODE HD4A = 5, HD5A = 7, CODE DIS6D INTO HD6A AND ASK HD7. IF HD1X = 4 AND DIS3D > 1, CODE HD4A = 4, HD5A = 7, CODE DIS6D INTO HD6A AND ASK HD7.
HD4A.	What type of medical care or advice did (you/the AGE AND GENDER PERSON #1/ #2/ #3/ #4) receive for this head injury? IF R ANSWERS ER OR HOSPITALIZED ASK: Was this an overnight admission? IF YES, CODE AS HOSPITALIZED. IF NO, CODE AS ER. NOTE: CODE 2 INCLUDES FAMILY, FRIENDS, OR NEIGHBORS WHO ARE HEALTH CARE PROVIDERS.		NONE 1 Phone call to a health care professional other THAN your own health care provider, not in a medical setting . (SKIP TO HD6A) 2 PHONE CALL TO HEALTH CARE PROVIDER’S OFFICE (SKIP TO HD6A) 3 DOCTOR’S OFFICE (SKIP TO HD6A) 4 EMERGENCY ROOM (SKIP TO HD6A) 5 HOSPITALIZED (SKIP TO HD6A) 6 OTHER (SPECIFY AND SKIP TO HD6A) 7 DK (SKIP TO HD6A) 98 RF (SKIP TO HD6A) 99 N/A (SKIP) 97
HD4A CODE.	SPECIFY:
	EDITOR NOTE: USE CODES 8 TO 95, 98=DK, 99=RF, 97=N/A(SKIP) ONLY IN HD4A.
HD5A.	What was the main reason (you/the AGE AND GENDER PERSON #1/ #2/ #3/ #4) did not receive medical care or advice for this head injury?		DIDN’T NEED/WANT CARE 1 COULD NOT TAKE TIME FROM WORK 2 NO TRANSPORTATION 3 NO HEALTH INSURANCE 4 OTHER (SPECIFY) 5 DK 98 RF 99 N/A (SKIP) 97
HD5A CODE.	SPECIFY:
	EDITOR NOTE: USE CODES 6 TO 95, 98=DK, 99=RF, 97=N/A(SKIP) ONLY IN HD5A.

HD6A.	What was the cause of this head injury? Was it a motor vehicle crash, sports or recreation related, a fall not related to sports or recreation, an assault, or something else?						MOTOR VEHICLE CRASH 1 SPORTS OR RECREATION 2 FALL, NOT SPORTS OR RECREATION RELATED 3 ASSAULT 4 OTHER (SPECIFY) 5 DK 98 RF 99 N/A (SKIP) 97
HD6A CODE.	SPECIFY:
	EDITOR NOTE: USE CODES 6 TO 95, 98=DK, 99=RF, 97=N/A(SKIP) ONLY IN HD6A.
HD7.	During the past 12 months, that is since (MONTH, YEAR), how many (other) people living in your household experienced a head injury or blow to the head in which they were knocked out or unconscious, suffered a concussion or memory loss, or were dazed or confused?						NUMBER NONE (SKIP TO SCRIPT) 0 DK (SKIP TO SCRIPT) 8 RF (SKIP TO SCRIPT) 9 N/A (SKIP) 7
		HD8.						HD9.
HD8. – HD9.		Please tell me the age and sex of each person in your household who experienced a head injury during the past 12 months like the one mentioned above. IF MORE THAN 4 PEOPLE, RECORD THE FOUR WITH THE MOST RECENT HEAD INJURIES. IF THE RESPONDENT OFFERS THAT PERSON SPECIFIED HAS HAD MULTIPLE HEAD INJURIES, COLLECT INFORMATION ON THE MOST SEVERE AS DETERMINED BY THE RESPONDENT.						Is this person a male or a female?
		AGE	DK	RF	N/A(SKIP)			MALE	FEMALE	DK	RF	N/A (SKIP)
	01.		98	99	97			1	2	8	9	7
	02.		98	99	97			1	2	8	9	7
	03.		98	99	97			1	2	8	9	7
	04.		98	99	97			1	2	8	9	7
	PROGRAMMER NOTE: REPEAT HD2A – HD6A FOR FIRST PERSON USING QUESTIONS HD2B – HD6B. REPEAT HD2A – HD6A FOR SECOND PERSON USING QUESTIONS HD2C – HD6C. REPEAT HD2A – HD6A FOR THIRD PERSON USING QUESTIONS HD2D – HD6D. REPEAT HD2A – HD6A FOR FOURTH PERSON USING QUESTIONS HD2E – HD6E.
	IF HD1 > 1 AND HD7 = 0, 7, 8, 9, SKIP TO WP1. SCRIPT: We are finished with the head injury questions now. The Brain Injury Association of America can provide you with more information on the many services available to those with head injuries. If you have a pencil and paper, I can give you that number now if you are interested. IF RESPONDENT INDICATES THEY WANT THE NUMBER: The number is 1-800-444-6443, this is the Family Helpline.
HD SCRIPT	PROGRAMMER NOTE: IF SCRIPT S NOT READ, CODE 7 IN HDSCRIPT. IF SCRIPT IS READ, CODE 2 IN HDSCRIPT. IF PHONE NUMBER IS PROVIDED, CODE 1 IN HDSCRIPT.
MODULE 6: WILLINGNESS TO PAY TO PREVENT CHILD MALTREATMENT
The next few questions are about funding of programs to prevent child maltreatment. Child maltreatment is the physical or sexual abuse of a child or the neglect of a child’s basic needs by their parents or caretakers. Child maltreatment can cause major physical or emotional harm, or death. Victims of maltreatment are more likely to have long-term health and social problems like higher risk for drug abuse, suicide, and trouble in school.
	PROGRAMMER NOTE: RANDOMLY ASSIGN RESPONDENT TO PATH = A, B, C, OR D; VERSION = 1 OR 2; AND ANCHOR = 1, 2, OR 3 AND INCLUDE THESE 3 VARIABLES IN DATA SET.
READ ONLY THE INTRODUCTION RELEVANT TO THE PATH THE RESPONDENT WAS ASSIGNED. A: Based on national data, 2 out of every 100,000 children annually, or an average of four children every day, are killed as a result of child maltreatment by their parents or caretakers. B: One type of child maltreatment is physical abuse. Physical abuse is defined as an injury or risk of an injury to a child resulting from having been hit with a hand or object or having been beat, kicked, bit, choked, stabbed, or burned, or otherwise physically harmed. Based on national data, 2 out of every 1,000 children annually, or an average of 460 children every day are victims of physical abuse by their parents or caretakers. C: One type of child maltreatment is sexual abuse. Sexual abuse involves any sexual activity with a child where consent is not or cannot be given. This includes all sexual contacts between an adult caretaker and a child. Based on national data, 1 out of every 1,000 children annually, or an average of 240 children every day are victims of sexual abuse by their parents or caretakers. D: One type of child maltreatment is neglect. Neglect refers to the failure to provide for a child’s basic physical, emotional, and medical needs. Neglect includes the failure to protect a child from harm, provide adequate food or shelter, or provide appropriate health care. Neglect also includes disregard of a child’s needs for affection and attention. Based on national data, 7 out of every 1,000 children annually, or an average of 1,460 children every day are victims of neglect by their parents or caretakers.
WP1.	How would you judge a child’s chance of being (A: killed/B: physically abused/C: sexually abused/ D: neglected) as a result of child maltreatment in your city or town? Would you say (READ ANSWERS)?						Much greater than average 1 Somewhat greater than average 2 About average 3 Somewhat less than average 4 Much less than average 5 DK 8 RF 9

Now imagine there is a program available to your city or town that is proven effective in reducing the risk of a child being… A: …killed by a parent or caretaker (version 1: by 50%/version 2: by 25%). This means that the number of children killed on average every day by child maltreatment is reduced from (version 1: 4 per day to 2 per day/version 2: 4 per day to 3 per day). B: …physically abused by a parent or caretaker (version 1: by 50%/version 2: by 25%). This means that the number of children physically abused on average every day is reduced from (version 1: 460 per day to 230 per day/version 2: 460 per day to 345 per day). C: … sexually abused by a parent or caretaker (version 1: by 50%/version 2: by 25%). This means that the number of children sexually abused on average every day is reduced from (version 1: 240 per day to 120 per day/version 2: 240 per day to 180 per day). D: … neglected by a parent or caretaker (version 1: by 50%/version 2: by 25%). This means that the number of children neglected on average every day is reduced from (version 1: 1460 per day to 730 per day/version 2: 1,460 per day to 1100 per day).
WP2.	If this program were available to your city or town, would you be willing to pay (anchor 1: $75/ anchor 2: $175/anchor 3: $275) in extra taxes per year to sponsor this program given your household income and other expenses?		yes 1 no (skip to wp3b) 2 dk (skip to wp3b) 8 rf (skip to wp3b) 9
wp3a.	Would you be willing to pay ($ANCHOR + $50)?		yes (SKIP TO WP4) 1 no (SKIP TO WP4) 2 dk (SKIP TO WP4) 8 rf (SKIP TO WP4) 9 N/A (SKIP) 7
wp3B.	Would you be willing to pay ($ANCHOR - $50)?		yes 1 NO 2 dk 8 RF 9 N/A (SKIP) 7
WP4.	Now thinking about your household income and other expenses, how confident are you in your previous answers about whether you would be able to pay for this child maltreatment prevention program? Are you (READ ANSWERS)?		Very confident 1 Somewhat confident 2 Not too confident 3 Not at all confident 4 DK 8 RF 9
			98 = DK, 99=RF
(WP5)	By the tine you started 6th grade, how often had you parents or other adult care givers (READ OPTIONS)? (PROMPT: 6th grade is when you were 11 years old.) Would you say (READ ANSWERS)?		More than 3-5 6-10 10 Once Twice times times times Never
	slapped hit or kicked you touched you I a sexual way, forced you to touch him or her in a sexual way, or forced you to have sexual relations not provided for your basic physical, emotional or medical needs		01 02 03 04 05 06 01 02 03 04 05 06 01 02 03 04 05 06

MODULE 7: FIREARM OWNERSHIP AND ACCESS
The next few questions are about firearms. We are interested only in firearms that work. Include handguns, pistols, rifles, and automatic or semi-automatic weapons. We are not interested in BB and pellet guns, tear gas guns, and guns that can’t fire, such as antiques and guns for display. (PROMPT: We are not interested in paintball guns.)
FX1.	During the past 12 months, that is since (MONTH, YEAR), were any firearms kept in or around your home? Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.		yes 1 no (skip to fx3) 2 dk (skip to fx3) 8 rf (skip to fx3) 9
FX2.	Were any of the firearms handguns, such as pistols or revolvers?		yes 1 no 2 dk 8 rf 9 n/a (skip) 7
FX3.	If you were at home, could you get and be ready to fire a loaded firearm in less than 10 minutes? The weapon could be yours or someone else’s, and it could be located in your home or car or someone else’s home or car. NOTE: IF THEY CAN GET THE GUN BUT DON’T KNOW HOW TO FIRE IT ON THEIR OWN, CODE “NO”.		yes 1 no (SKIP TO PR1) 2 DK (SKIP TO PR1) 8 RF (SKIP TO PR1) 9
FX4.	Does the firearm that you could get and fire in less than 10 minutes belong to you personally, another member of your household, or someone else?		Self 1 member of household 2 someone else 3 dk 8 rf 9 n/a (skip) 7

MODULE 8: PERPETRATION
People sometimes hit or strike other people. When people strike others it can put them and the other person at risk for being injured. It is important for us to know how often people strike other people so that we can better understand this risk. The next few questions ask about different people that you may have struck on purpose. By “struck” I mean times when you have hit, slapped, pushed, or kicked a person or times when you hit someone with an object or weapon. PROGRAMMER NOTE: SHOW THE ABOVE SENTENCE DEFINING “STRUCK” AS A PROMPT ON SCREENS FOR PF1, PR2, PR4, PR5, PR7, PR8 AND PR10. Sometimes people strike other people in these ways because they are angry, have some sort of problem, need something from that person, or because they are trying to protect themselves from that person, like in self-defense. We are not going to ask you why you struck someone. We are only going to ask you whether it happened. All of your answers will be kept private.
PR1.	Since you turned 18 years old, on how many occasions have you struck a stranger for any reason? If you have a job that authorizes you to use force, for example if you are a police officer or security guard, do not include incidents that happened while you were at work. (PROMPT: An approximate number is okay).		number of OCCASIONS none (skip to pr4) 0 dk 98 rf 99
	PROGRAMMER NOTE: if r turned 18 in the past 12 months, code pr2 = pr1.
pr2.	On how many occasions have you struck a stranger for any reason in the past 12 months, that is since (MONTH, YEAR)?		number of occasions none (SKIP TO PR4) 0 DK (SKIP TO PR4) 98 RF (SKIP TO PR4) 99 n/a (skip) 97
pr3.	How many of these occasions in the past 12 months, if any, resulted in you talking to the police?		number of occasions none 0 dk 98 rf 99 n/a (skip) 97
pr4.	Since you turned 18 years old, on how many occasions have you struck a current or former spouse, (boyfriend/girlfriend) or dating partner for any reason? (PROMPT: An approximate number is okay).		number of OCCASIONS none (skip to pr7) 0 dk 98 rf 99
	PROGRAMMER NOTE: if r turned 18 in the past 12 months, code pr5 = pr4.
pr5.	On how many occasions have you struck a current or former spouse, (boyfriend/girlfriend) or dating partner for any reason in the past 12 months (that is since [MONTH, YEAR])?		number of occasions none (skip to pr7) 0 NO SUCH PERSON IN PAST 12 MONTHS (skip to pr7) 96 DK (SKIP TO PR7) 98 RF (SKIP TO PR7) 99 n/a (skip) 97
pr6.	How many of these occasions in the past 12 months, if any, resulted in you talking to the police?		number of occasions none 0 dk 98 rf 99n/a (skip) 97

pr7.	Since you turned 18 years old, how many times have you struck an adult that you knew, like a friend or acquaintance, for any reason? (PROMPT: An approximate number is okay).		number of OCCASIONS none (skip to pr10) 0 dk 98 rf 99
	PROGRAMMER NOTE: if r turned 18 in the past 12 months, code pr8 = pr7.
pr8.	On how many occasions have you struck an adult that you knew, like a friend or acquaintance for any reason in the past 12 months (that is since [MONTH, YEAR])?		number of occasions none (SKIP TO PR10) 0 DK (SKIP TO PR10) 98 RF (SKIP TO PR10) 99 n/a (skip) 97
pr9.	How many of these occasions in the past 12 months, if any, resulted in you talking to the police?		number of occasions none 0 dk 98 rf 99n/a (skip) 97
pr10.	Since you turned 18 years old, on how many occasions have you struck your child or a child that you were responsible for? (PROMPT: An approximate number is okay).		number of OCCASIONS none (skip to sCRIPT) 0 dk 98 rf 99
pr11.	How many of these occasions, if any, resulted in you talking with a child protective services worker?		number of occasions none 0 dk 98 rf 99 n/a (skip) 97
	SCRIPT: We are finished with the perpetration questions now. Remember, if you or anyone else you know is in danger, you can always dial 911.

MODULE 9: SUICIDE
The next set of questions is about suicidal feelings and behavior. These can be sensitive questions. Please try to answer them to the best of your ability.
SX1.	During the past 12 months, that is since (MONTH, YEAR), have you had thoughts of taking your own life, even if you would not really do it?		yes 1 no 2 DK 8 RF 9
SX2.	During the past 12 months, how many times have you deliberately harmed or injured yourself – even if you did not intend to die?		NUMBER OF TIMES NONE (SKIP TO SX5) 0 DK (SKIP TO SX5) 98 RF (SKIP TO SX5) 99
SX3.	During the past 12 months, how many times have you attempted to end your own life?		NUMBER OF TIMEs NONE 0 DK 98 RF 99 N/A (SKIP) 97
SX4.	When you last (attempted suicide/harmed yourself) what final outcome did you most intend? Would you say (READ ANSWERS)?		Intended not to be injured 1 Intended to be injured but to survive 2 Intended to die 3 You are not sure what you intended 4 DK 8 RF 9 n/a (skip) 7
The next few questions are about your recent feelings and experiences.
SX5.	How much do you agree with the following statement - Overall, I expect more good things to happen to me than bad. Would you say you (READ ANSWERS)?		Strongly agree 1 Agree 2 Neither agree nor disagree 3 Disagree 4 Strongly disagree 5 DK 8 RF 9
SX6.	During the past 12 months, were you limited in any way in any activities because of depression, anxiety, or emotional problems?		YES 1 NO 2 DK 8 RF 9
SX7.	During the past 12 months, how often have you been treated unfairly in your job, by the police, by neighbors, or in any other situation because of your race or ethnicity? Would you say (READ ANSWERS)?		Never 1 Once in a while 2 Some days 3 Most days 4 Every day 5 Many times a day 6 DK 98 RF 99
SX8.	How often do you find strength and comfort in your religion or spirituality? Would you say (READ ANSWERS)?		Never 1 Once in a while 2 Some days 3 Most days 4 Every day 5 Many times a day 6 no religion 96 DK 98 RF 99

		SCRIPT: Before we move onto the next set of questions we are giving all respondents the phone number for the National Crisis Hotline. If you have a pencil and paper I can give you that number now. IF RESPONDENT INDICATES THEY WANT THE NUMBER: The number is 1-800-SUICIDE (784-2433), this is the National Crisis Hotline. If you would like, I can stop the interview now and connect you directly with a confidential counselor at the hotline and then call you back in a few days to complete the final interview questions or we can complete the interview now and you can call the hotline on your own after we have finished.

MODULE 10: INCOME
We are almost done now. I want to learn just a little bit more about you.
POVERTY	COMPUTER WILL ASSIGN HOUSEHOLD A POVERTY THRESHOLD BASED ON NUMBER OF ADULTS AND CHILDREN. IF NUMBER OF ADULTS OR NUMBER OF CHILDREN IS UNKNOWN, STORE 99998 IN POVERTY.
INC1	Would you tell me which category best represents the total income brought in before taxes during the past 12 months by all members of your household? READ ANSWERS.		Under $20,000 1 $20,000 or more (SKIP TO INC3) 2 DK (STORE 8 IN INC5 AND SKIP TO END) 8 RF (STORE 9 IN INC5 AND SKIP TO END) 9
INC2	Was it under $10,000 or over $10,000? INCLUDE $10,000 AS OVER.		UNDER 1 OVER 2 DK 8 RF 9 N/A (SKIP) 7
	PROGRAMMER NOTE: IF POVERTY=99,998, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC2=1 AND POVERTY > = 10,000, THEN STORE 1 IN INC5 AND SKIP TO END. IF INC2=1 AND POVERTY < 10,000, THEN SKIP TO INC5. IF INC2=2 AND POVERTY > = 10,000 BUT <20,000, THEN SKIP TO INC5. IF INC2=2 AND POVERTY < 10,000, THEN STORE 2 IN INC5 AND SKIP TO END. IF INC2=2 AND POVERTY > = 20,000, THEN STORE 1 IN INC5 AND SKIP TO END. IF INC2=8 OR 9 AND POVERTY > = 20,000, THEN STORE 1 IN INC5 AND SKIP TO END. IF INC2=8 AND POVERTY < 20,000, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC2=9 AND POVERTY < 20,000, THEN STORE 9 IN INC5 AND SKIP TO END.
INC3	Was it under $35,000 or over $35,000? INCLUDE $35,000 AS OVER.		UNDER 1 OVER (ASK INC4) 2 DK 8 RF 9 N/A (SKIP) 7
	PROGRAMMER NOTE: IF POVERTY=99,998, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC3=1 AND POVERTY > = 20,000 BUT < 35,000, THEN SKIP TO INC5. IF INC3=1 AND POVERTY < 20,000 THEN STORE 2 IN INC5 AND SKIP TO END. IF INC3=1 AND POVERTY > = 35,000, THEN STORE 1 IN INC5 AND SKIP TO END. IF INC3=8 OR 9 AND POVERTY < 20,000, THEN STORE 2 IN INC5 AND SKIP TO END. IF INC3=8 AND POVERTY > = 20,000, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC3=9 AND POVERTY > = 20,000, THEN STORE 9 IN INC5 AND SKIP TO END.
INC4	Was it under $50,000 or over $50,000? INCLUDE $50,000 AS OVER.		UNDER 1 OVER 2 DK 8 RF 9 N/A (SKIP) 7

	PROGRAMMER NOTE: IF POVERTY=99,998, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC4=1 AND POVERTY > = 35,000 BUT < 50,000, THEN SKIP TO INC5. IF INC4=1 AND POVERTY < 35,000, THEN STORE 2 IN INC5 AND SKIP TO END. IF INC4=2, THEN STORE 2 IN INC5 AND SKIP TO END. IF INC4=8 OR 9 AND POVERTY < 35,000, THEN STORE 2 IN INC5 AND SKIP TO END. IF INC4=8 AND POVERTY > = 35,000, THEN STORE 8 IN INC5 AND SKIP TO END. IF INC4=9 AND POVERTY > = 35,000, THEN STORE 9 IN INC5 AND SKIP TO END.
INC5.	Was it under or over (POVERTY)? INCLUDE EQUAL TO POVERTY THRESHOLD AS OVER.		UNDER 1 OVER 2 DK 8 RF 9

	CLOSING SCRIPT
	Thank you for your time and help with this survey. Lastly, I have a statement I’m required to read to you. If the survey has taken longer than expected, or if you have comments about this survey, you are invited to send comments regarding this burden or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; Attn: PRA (0920-0513). In appreciation for your time and effort I now need to know whether you would prefer to receive the phone card, that is a card that will provide 100 minutes of pre-paid long distance phone service, or have $5.00 donated to the United Way. The phone card can be sent to any name and address you choose. Which option would you prefer? RECORD OPTION CHOSEN. Thanks again.
			CHARITABLE DONATION ..……………………….1 PHONE CARD ……………………………………….2
			END TIME :

MODULE 11: INTERVIEWER EVALUATION AND COMMENTS
EV1.	Language in which the interview was conducted? FILL IN THIS INFORMATION FROM THE SCREENER SECTION.					ENGLISH 1 SPANISH 2
EV2.	Was the respondent’s cooperation:					VERY GOOD 1 GOOD 2 FAIR 3 POOR 4
EV3.	How would you rate the truthfulness of the respondent’s answers?					VERY GOOD 1 GOOD 2 FAIR 3 POOR 4
EV4.	The quality of the interview was:					HIGH QUALITY (SKIP TO EV6) 1 ABOVE AVERAGE QUALITY (SKIP TO EV6) 2 AVERAGE QUALITY (SKIP TO EV6) 3 BELOW AVERAGE QUALITY 4 LOW QUALITY 5
EV5.		The main reason for the below average or low quality was that the respondent appeared to be:				ILL OR DISABLED 01 SPEAKING ENGLISH/SPANISH POORLY 02 EVASIVE OR SUSPICIOUS 03 BORED OR UNINTERESTED 04 UPSET OR DEPRESSED BY THE TOPIC 05 DRUNK OR MENTALLY IMPAIRED 06 HAVING POOR HEARING OR SPEECH 07 CONFUSED BY FREQUENT INTERRUPTIONS 08 INSUFFICIENTLY KNOWLEDGEABLE 09 INTERVIEW TOO LONG 10 CONFUSED BY SURVEY 12 BAD CONNECTION 13 HOSTILE 14 IMPATIENT/RUSHED 15 DISTRACTED 16 DIDN’T WANT TO DO 17 KEPT TALKING 18 THOUGHT SURVEY SILLY/STUPID 19 SOMETHING ELSE (SPECIFY) 11 N/A (SKIP) 97
EV5 CODE		SPECIFY:
		EDITOR NOTE: USE CODES 20-95 ONLY IN EV5CODE.
EV6.			Do you have any other relevant observations, comments or impressions about this interview?				YES 1 NO (SKIP TO EV7) 2
			RECORD COMMENTS:

EV7.	Were there any questions with which you had difficulty?		YES 1 NO (END) 2
	RECORD QUESTIONS AND PROBLEM:
EV TIME	PROGRAMMER NOTE: RECORD TIME IN SECONDS FOR COMPLETION OF THIS SECTION.

Sources of Survey Questions, ICARIS-2 Phase-2

Screener Script

SC1 adapted from ICARIS 1, ICARIS-2 (SC1)

SC2-SC3 new questions

SC4 adapted from ICARIS-1, ICARIS-2 (SC2)

SC5 ICARIS-1, ICARIS-2 (SC5)

Demographics and Home

DH1-2A ICARIS 1, ICARIS-2 (DH1-DH2A)

DH3-DH8 ICARIS 1 (D1-D4), ICARIS-2 (D1-D6)

DH9-DH10 ICARIS 1, ICARIS-2 (DH5, D7)

DH11-DH12 ICARIS 1 (D5-D6), ICARIS-2 (DH6-DH7)

DH12A new question

Older Adult Mobility

MOBL1 Nationwide Personal Transportation Survey, ICARIS-2 (MV6).

MOBL2,3 new questions

MOBL4 ICARIS-2 (MV3a,b,d,e)

MOBL5 new question

MOBL6 adapted from ICARIS-2 (FE7)

MOBL7 ICARIS-2 (FE4) and BRFSS

MOBL8-9 new question

Child Supervision

SUPR1,4,5 new questions

SUPR2,3 not applicable – age/sex enumeration of children in household under 18 years

SUPR6-12 Morrongiello, B. A., L. Ondejko, and A. Littlejohn. 2004. "Understanding toddlers' in-home

injuries: I. Context, correlates, and determinants." Journal of Pediatric Psychology 29:415-31.

Tomlinson, R. and C. Sainsbury. 2004. "Childhood injury prevention advice: a survey of health

professionals responses to common scenarios." Child Care Health Dev 30:301-5.

Injury and Disability

DIS1,2 adapted from the National Health Interview Survey (NHIS) Disability Supplement, p146.

DIS3 adapted from NHIS

DIS4 Health Interview Survey (HIS) Disability Supplement

DIS5 Violence and Threats of Violence Against Women in America Female Questionnaire

DIS6 adapted from NHIS, Disability Supplement, p140 (modified).

DIS7 adapted from Health Interview Survey (HIS) Disability supplement

DIS8,10,11 adapted from the NHIS, Disability Supplement and from

Violence and Threats of Violence Against Women in America Female Questionnaire

DIS9 adapted from NHIS (ADLs, IADLs, and activity limitations) Disability Supplement and from

Violence and Threats of Violence Against Women in America Female Questionnaire

Traumatic Brain Injury

HD1,7 adapted from the NHIS Family Section - Section III - Injuries

HD2-3 new questions

HD4,6 adapted from the NHIS Family Core Section III - Injuries

HD5 adapted from the NHIS Adult Core Section V Part C - Health Care Access and

Utilization

HD8,9 not applicable – age/sex enumeration of household members with a head injury

OMB numbers for selected studies referenced above are as follows:

ICARIS-1, OMB clearance number 0920-0342; ICARIS-2, OMB clearance number 0920-0513;

Sources of Survey Questions, ICARIS-2 Phase-2, continued.

Willingness to Pay to Prevent Child Maltreatment

WP1-4 Based on instrument used by Hammitt JK & Graham JD. Willingness to pay for health protection: Inadequate sensitivity to probability. Journal of Risk and Uncertainty. 1999;18:33-62.

WP5a,b,c National Longitudinal Study of Adolescent Health(AdHealth), Wave III, 2001-2002 (H3MA3,H3MA4, and

H3MA2-adapted)

Firearm Access

FX1,2 Adapted from BRFSS Firearm module, ICARIS-2 (FA1,FA2)

FX3 ICARIS-1 (G18)

FX4 new question

Perpetration

PR1,4,7,10 ACTIVA Study, modified version

PR2,5,8 ACTIVA Study, modified version

PR3,6,9 ,11 new questions

Suicide

SX1 ICARIS-1 (S1). Original source: Paykel ES, Myers JD, Lindenthal JJ, Tanner J. Need

Suicidal feelings in the general population: A prevalence study. British Journal of Psychiatry, 1974; 124:460-469. ICARIS-2 (S1)

SX2,4 adapted from the Parasuicide History Interview by Linehan, unpublished.

SX3 ICARIS-1 (S4,S5) - modified from original 1997 YRBS source. ICARIS-2 (S5).

SX5 Scheifer MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self mastery and self esteem): A reevaluation of the Life Orientation Test. Journal of personality and Social Psychology.1994:67:1063-78.

SX6 1999 BRFSS, Supplemental Quality of Life questionnaire.

SX7 adapted from Forman TA, Williams DR, Jackson JS. Race, place and

discrimination. Perspectives on Social Problems. 1997;9:231-261.

SX8 Daily Spiritual Experience Scale, 6-item version. General Social Survey.

Income

INC1-4 ICARIS-1 (D8-D14), ICARIS-2 (D8-D12)

OMB numbers for selected studies referenced above are as follows:

ICARIS-1 OMB clearance number 0920-0342; ICARIS-2 OMB clearance number 0920-0513;

NHIS OMB clearance number 0920-0214.

Note: It is our undetstanding that there are no OMB clearance numbers associated with the BRFSS or

the Adolescent Health survey.

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