Form Approved:
OMB Number 0920-
Expiration Date:
FD Survey ID code __________
GET ALARMED, NORTH CAROLINA!
6-Month Post-Intervention Follow up Telephone Survey
Preloaded Information:
NOTE: This information will be added to the follow-up telephone survey as fill fields in MS Word. The fill fields will customize the survey form to each individual so that introductions and questions will be asked in an appropriate manner. This information will also help to reduce the total number of questions to be asked in the survey.
This draft follows standard telephone survey specifications. All text in CAPS (Interviewer instructions or volunteered responses) is not to be read by the telephone interviewer (TI).
Case ID Number
Name (first, middle, last)
Home telephone
All demographic information from pre-evaluation survey
Whether or not the household has children under the age of 18
Date of installation/intervention
Number of alarms installed
Fire Department
Presence of fireplaces or wood stoves in the home
Public
Reporting burden of this collection of information is estimated at
15 minutes per response, including the tine for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the
collection of information. An agency many 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/ATSDR Reports Clearance Officer, 1600 Clifton
Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX)
Intro2. The person who spoke with the fire department representative was {fill name}. Am I speaking with {fill name}?
Yes (SKIP TO #1)
No (SKIP TO Intro3a)
Intro3a. Does {fill name} still live at this address?
Yes (SKIP TO Intro3b)
No (SKIP TO Intro3c)
Intro3b. May I speak to {fill name}?
Yes
No/Not available
If YES: When resident comes to the phone, repeat the Introduction 1 & proceed to question number 1.
If No/Not available, “Is there a day and time that I could call back when {fill name} might be available?”
If YES: When would be a good time to reach {fill name}?
Day of Week and Time of Day: ______________________
“We will have someone call back at that time.”
Intro3c. Thank you for your time. Good bye. {End call.}
Follow-up Survey Questions
1. Do you recall the {fill fire department} installing {fill number of alarms installed} smoke alarm(s) on {fill date of installation}?
TI: IF RESPONDENT SAYS NO/DK/RF, BEFORE YOU CODE THIS ITEM, SAY: “The information I have here says that someone from the {fill fire department} visited your home on {fill date of installation}. During this visit, the fire fighter may have installed fire alarms and spoken to you about how to prevent fires in your home. Do you recall this visit?”
YES
NO (SKIP TO closing remarks)
DON’T KNOW (SKIP TO closing remarks)
REFUSED (SKIP TO closing remarks)
2. Have you installed additional alarms in your home since the Fire Department installed the {fill number of alarms installed} alarm(s)?
YES
NO (SKIP TO Q4)
DON’T KNOW (SKIP TO Q4)
REFUSED (SKIP TO Q4)
3a. How many additional alarms have you installed in your home?
TI: Record number of additional alarms _________________________
DON’T KNOW
REFUSED
3b. Where (in what room(s)) was/were the alarm(s) installed? TI: RECORD VERBATIM RESPONSE
____________________________________________________________________________________________________________________________________________________
4. How often do you test your smoke alarm(s)? Would you say…
Monthly
Two times a year
One time a year, or
Never (SKIP TO Q6a)
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW (SKIP TO Q6a)
REFUSED (SKIP TO Q6a)
5. When was the last time you checked your smoke alarm? Would you say…
Last month
6 months ago
Last year
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
6a. Are you able to test your alarm?
YES
NO (SKIP TO Q6d1)
6b. Can you test it now, while I am on the phone with you?
YES (SKIP TO Q6c)
NO (SKIP TO Q6d1)
6c. TI: DO YOU HEAR THE ALARM?
YES (SKIP TO Q7)
NO (SKIP TO Q7)
6d1. Can you tell me why you can’t test your alarm? TI: CODE ALL THAT APPLY
SOMEONE TESTS IT FOR ME (Ask Q6d2)
ALARM(S) IS IN ANOTHER PART OF THE HOUSE
DON’T HAVE TIME
DIFFICULT TO TEST
OTHER (VOLUNTEERED, SPECIFY)___________________________
6d2. How often does someone check it for you? Would you say…
Every month
Two times a year
One time a year, or
Never
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
7.Do you do anything to take care of your alarm(s)?
YES
NO (SKIP TO Q9)
DON’T KNOW (SKIP TO Q9)
REFUSED (SKIP TO Q9)
8. What do you do to take care of it? TI: CODE ALL THAT APPLY
Keep it clear of cobwebs and debris
Keep obstacles away from it
Vacuum it out occasionally
Keep it out of drafts
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
9. If a fire were to start in your home, do the members of your household have an escape plan?
YES
NO (SKIP TO Q11)
DON’T KNOW (SKIP TO Q11)
REFUSED (SKIP TO Q11)
10. In the past 6 months how many times have you and the members of your household practiced using your escape plan? Would you say…
None
1-2 times
3-5 times, or
More than 5 times
DON’T KNOW
REFUSED
11. Since we visited your home and installed your alarm(s) have you had a fire in your home?
YES
NO (SKIP TO Q12)
DON’T KNOW (SKIP TO Q12)
REFUSED (SKIP TO Q12)
11a_1. How many fires have you had in your home since your alarm(s) were installed?
TI: RECORD NUMBER: _______
DON’T KNOW
REFUSED
TI: IF Q11_a1 IS MORE THAN ONE (1), TELL THE RESPONDENT: “For the next few questions, I’d like you to tell me about the fire that did the most damage to your home.”
11a_2. Did the smoke alarm sound?
YES
NO
DON’T KNOW
REFUSED
11b. How many people were at home at the time of the fire?
TI: ENTER NUMBER_______________________
DON’T KNOW
REFUSED
11c1. In what room or rooms of your house did the fire start? TI: DO NOT READ, CODE ALL THAT APPLY
KITCHEN
LIVING ROOM
UTILITY ROOM
GARAGE
LAUNDRY ROOM
BEDROOM
BATHROOM
HALLWAY
PORCH
OTHER (SPECIFY)_____________________________________
DON’T KNOW
REFUSED
11c2. What was the cause of the fire? TI: DO NOT READ, CODE ALL THAT APPLY
COOKING FIRE
CLOTHES CAUGHT FIRE WHILE COOKING
OVEN MITTS/POT HOLDERS CAUGHT FIRE WHILE COOKING
HEATING SYSTEM MALFUNCTIONED/CAUGHT FIRE
FAULTY WIRING
DID NOT PUT CIGARETTE OUT COMPLETELY
SOMEONE FELL ASLEEP WHILE SMOKING IN BED
SOMEONE FELL ASLEEP WHILE SMOKING ON THE COUCH/IN A CHAIR
CHILDREN PLAYING WITH MATCHES
CANDLES
PORTABLE HEATER
KEROSENE HEATER
FIREPLACE
WOOD STOVE
DRINKING ALCOHOLIC BEVERAGE
SPILLED AN ALCOHOLIC BEVERAGE
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
11d. Was anyone injured because of the fire?
YES
NO (SKIP TO Q11g)
DON’T KNOW (SKIP TO Q11g)
REFUSED (SKIP TO Q11g)
11e. What kind of injuries did members of your household receive because of this fire? TI: DO NOT READ, CODE ALL THAT APPLY
BURNS
SMOKE INHALATION
SPRAINS
BROKEN BONES
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
11f. Did anyone who was injured because of this fire seek medical attention?
YES
NO
DON’T KNOW
REFUSED
11g. Did the members of your household utilize a fire escape plan when this fire happened?
YES
NO
DON’T KNOW
REFUSED
11h. How was the fire put out? TI: DO NOT READ, CODE ALL THAT APPLY
FIRE EXTINGUISHER
WATER
FIRE DEPARTMENT
SMOTHERED WITH A LID, POT OR BLANKET
OTHER (VOLUNTEERED, SPECIFY)___________________________
DON’T KNOW
REFUSED
12. Do you think that the fire safety education you received from the fire department helped you to prevent fires?
YES
NO
DON’T KNOW
REFUSED
13. Were you happy with the fire safety education, materials and alarms the firefighter provided to you?
YES
NO
DON’T KNOW
REFUSED
14. Which information did you find the most helpful? TI: RECORD VERBATIM RESPONSE
_________________________________________________________________________
_________________________________________________________________________
15. Which information did you find the least helpful? TI: RECORD VERBATIM RESPONSE
_________________________________________________________________________
_________________________________________________________________________
16. In the past 6 months, have you bought any of the following fire safety products…?
16a. Fire Extinguishers
YES
NO
DON’T KNOW
REFUSED
16b_1. Smoke Alarms that use standard batteries
YES
NO
DON’T KNOW
REFUSED
16b_2. Smoke Alarms that use long lasting (long life) batteries (Do not include the alarms you received when the fire department visited)
YES
NO
DON’T KNOW
REFUSED
16b_3. Smoke Alarms that use your house’s electricity (Do not include the alarms you’ve received today)
YES
NO
DON’T KNOW
REFUSED
16c. Fire Escape Ladders
YES
NO
DON’T KNOW
REFUSED
16d. An alarm added to your home security system that alerts the fire department in case of a fire
YES
NO
DON’T KNOW
REFUSED
16e. Some other type of fire safety product
YES
NO
DON’T KNOW
REFUSED
16e_other. What were the other items you’ve purchased? TI: RECORD VERBATIM RESPONSE
_______________________________________________________________________
_______________________________________________________________________
16f. ASK IF ANY OF THE QUESTIONS Q16A-Q16E=YES. Was there a reason that you purchased these products? TI: RECORD VERBATIM RESPONSE
_______________________________________________________________________
_______________________________________________________________________
17. In the past 6 months, how often have you used an electric space heater in your home? Would you say…
All of the time
Most of the time
Some of the time
Never (SKIP TO Q19)
DON’T KNOW (SKIP TO Q19)
REFUSED (SKIP TO Q19)
18. In the past 6 months, how often have you used extension cords with your electric space heaters? Would you say…
All of the time
Most of the time
Some of the time
Never
DON’T KNOW
REFUSED
19. In your opinion, if a space heater is being used in a home, how far away should people and things that may catch fire be kept away from a space heater? Would you say…
Less than 1 foot
1 foot to 3 feet
More than 3 feet
DON’T KNOW
REFUSED
ASK Q20-22 IF THERE IS A FIREPLACE OR WOOD STOVE IN THE HOME
20. If you use wood in your fireplace or wood stove, where do you keep the wood? Would you say…
Wood is stored somewhere inside the home
Wood is stored outside, less than 30 feet away from the home
Wood is stored outside, more than 30 feet away from the home
I DON’T USE WOOD IN MY FIREPLACE OR WOOD STOVE (volunteered, DO NOT READ)
DON’T KNOW
REFUSED
21. In the past 6 months, have you had your chimney(s) professionally cleaned?
YES
NO
DON’T KNOW
REFUSED
22. In the past 30 days, have you burned trash in your fireplace or wood stove?
YES
NO
DON’T KNOW
REFUSED
23. In the past 30 days, how often have you walked away (any distance) from food that is cooking on the stove or in your toaster oven? Would you say…
All of the time
Most of the time
Some of the time
Never
DON’T KNOW
REFUSED
24. In your opinion, if a grease fire starts in your kitchen, what should you do? Would you say…
TI: CODE ALL THAT APPLY
Move or carry the pan to the sink
Smother it with a tight fitting lid and turn the burner off
Pour water on the fire
Pour baking soda or salt on the fire
DON’T KNOW
REFUSED
25. During the past 30 days, has anyone who lives here had at least one entire drink of alcohol inside this home?
YES
NO
DON’T KNOW
REFUSED
26a. During the past 30 days, has anyone who lives here smoked cigarettes, cigars or pipes anywhere inside this home?
YES
NO (SKIP TO Q27)
DON’T KNOW (SKIP TO Q27)
REFUSED (SKIP TO Q27)
26b. During the past 30 days, how often has anyone who lives here smoked while lying down or sitting up in bed inside this home? Would you say…
All of the time
Most of the time
Some of the time
Never
DON’T KNOW
REFUSED
26c. During the past 30 days, how often has anyone who lives here smoked while sitting in a recliner or easy chair? Would you say…
All of the time
Most of the time
Some of the time
Never
DON’T KNOW
REFUSED
27. In your opinion, if a fire were to start in your home, how should you leave? Would you say…
Walk at a normal pace to an exit
Run to an exit
Stay low to the ground while moving toward an exit
DON’T KNOW
REFUSED
28. In your opinion, if a fire were to start in your home, how should you contact 911 or other emergency services? Would you say…
Find the closest phone in your home and call 911 or other emergency services
Leave your home and call 911 or other emergency services from a neighbor’s home or somewhere else
DON’T KNOW
REFUSED
ASK Q 29-31 ONLY IF THERE ARE CHILDREN UNDER 18 IN HH
29. Have you discussed fire safety with the children under the age of 18 in your household in the past 6 months?
YES
NO (SKIP TO Q30)
DON’T KNOW (SKIP TO Q30)
REFUSED (SKIP TO Q30)
Q29a. What do you discuss when talking to your children about fire safety? TI: RECORD VERBATIM RESPONSE
__________________________________________________________________________________________________________________________________________________________
30. Do you keep cigarette lighters, matches, and other things used to start fires in a safe place, where children under the age of 18 can’t get to them?
YES
NO
DON’T KNOW
REFUSED
31. Which of the following statements is true about your household? Would you say…
All of the cigarette lighters in my household are child proof
Some, but not all of the cigarette lighters in my household are child proof
None of the cigarette lighters in my household are child proof
THERE ARE NO CIGARETTE LIGHTERS IN MY HOUSEHOLD (VOLUNTEERED. DO NOT READ)
DON’T KNOW
REFUSED
32. When was the last time you had your home heating system cleaned, either by someone in your household or by a professional? Would you say…
I’ve never had it cleaned
Less than one year ago
One to two years ago
More than two years ago
DON’T KNOW
REFUSED
33. In the past 6 months, have you burned any of these things on your property? TI: CODE ALL THAT APPLY
Trash
Leaves
I DON’T BURN ANYTHING ON MY PROPERTY (VOLUNTEERED. DO NOT READ)
DON’T KNOW
REFUSED
34. In the past 30 days, when disposing of ashes from a fire, fire place, wood stove, ash tray, trash/leaf fire, grill or other type of fire, how often did you wet them down first? Would you say…
All of the time
Most of the time
Some of the time
I never wet down ashes before disposing of them
I HAVE NOT DISPOSED OF ASHES IN THE PAST 30 DAYS (VOLUNTEERED. DO NOT READ)
DON’T KNOW
REFUSED
CLOSING REMARKS:
Thank you for your time in answering my questions. This information will help us learn whether fire safety information is being presented in a way that people can easily remember. We appreciate your help. Do you have any questions about your smoke alarms or about fire safety education that you would like someone to call you back about?
If YES: “I will give your name and number to someone on the smoke alarm project and ask him or her to call you. Is there a good time to reach you at home?
Day of Week and Time of Day: ___________________________________________
We will have someone call back as soon as possible during that time to discuss your concerns. Thank you again. Goodbye.”
AS SOON AS CALL HAS ENDED, IF THERE IS A QUESTION: Enter name, address, phone number, survey number and date and time of this call as well as day of week and time of day that is best to return call on Excel program. Notify Sherri (Program Manager) of need to return call. Try to determine the nature of the question or even the actual question so Sherri can determine who is best to return the call.
| File Type | application/msword |
| File Title | Get Alarmed, North Carolina |
| Author | CDPCS |
| Last Modified By | Mick Ballesteros |
| File Modified | 2006-04-18 |
| File Created | 2005-08-01 |