2 Poison Help Survey Final

OMB Number 0915-XXXX

Expiration Date: _________

POISON HELP

GENERAL POPULATION SURVEY

INTRO 1. Hello, this is [INTERVIEWER] and I’m calling for the U.S. Health Resources and Services Administration, HRSA. We are contacting households across the nation to conduct a brief survey to learn how people get safety information. This voluntary interview will take about 10 minutes, and the information you give will be private. If you’re ready, let’s begin.

[INTERVIEWER NOTE: IF RESPONDENT ANSWERS TELEPHONE IN SPANISH OR REQUESTS SPANISH-LANGUAGE, READ INTRODUCTION IN SPANISH]

INTERVIEWER RECORD LANGUAGE:

1. ENGLISH

2. SPANISH

R1. First, I’m going to read descriptions of situations that might happen. Please tell me what you would do if that happened to you. What if…

[RANDOMLY ASSIGN RESPONDENTS TO 4 SCENARIOS]

1. A young child swallowed several adult vitamin pills

2. An older person visiting your household says that he may have taken his high blood pressure medication twice by mistake

3. A neighbor runs in and says she needs help because her child drank windshield wiper fluid

4. You think you have an insect bite and your arm becomes very swollen from wrist to elbow

5. You are looking for general information about ways to prevent poisoning

6. You hear on the news that there has been a recall of eggs in your State

7. The alarm on your carbon monoxide detector goes off in the middle of the night

8. You were using pesticides in your garden and now you are feeling ill

9. You hear on the radio that the water supply in your city has been contaminated and you are worried about whether it is safe to drink and use

10. Your spouse was helping you with cleaning the house, but is now having difficulty breathing

[INTERVIEWER PROMPT: “What would you do first if this happened?”]

[DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

1. POISON CENTER/POISON CONTROL CENTER/PCC

2. 911/RESCUE SQUAD/EMT

3. FIRE DEPARTMENT

4. POLICE DEPARTMENT

5. DOCTOR/NURSE/HEALTH PROFESSIONAL

6. PHARMACIST/PHARMACY

7. HOSPITAL/EMERGENCY ROOM

8. URGENT CARE

9. FAMILY MEMBER

10. FRIEND

11. INTERNET/ONLINE (Specify: _____)

12. NOTHING/WOULD NOT SEEK HELP

91. OTHER (Specify: _____)

98. DON’T KNOW

99 REFUSED

R2. In the past year, have you sought information or help related to a poisoning?

1. YES

2. NO

98. DON’T KNOW

99. REFUSED

[IF R2:1 YES, ASK R3. ALL OTHERS SKIP TO R5]

R3. In your own words, please describe the reason you sought information or help related to a poisoning.

[RECORD RESPONDENT ANSWER EXACTLY]

98. DON’T KNOW

99. REFUSED

R4. Please tell me where you sought information or help. [DO NOT READ / CODE ALL THAT APPLY]

1. POISON CENTER/POISON CONTROL CENTER/PCC

2. 1-800-222-1222 / POISON Help line / POISON 1-800 NUMBER / POISON HOTLINE

3. 911/RESCUE SQUAD/EMT

4. FIRE DEPARTMENT

5. POLICE DEPARTMENT

6. DOCTOR/NURSE/HEALTH PROFESSIONAL

7. PHARMACIST/PHARMACY

8. HOSPITAL/EMERGENCY ROOM

9. URGENT CARE

10. FAMILY MEMBER

11. FRIEND

12. INSURANCE COMPANY / INSURANCE ADVICE LINE / NURSE HELP LINE

13. INTERNET ONLINE (SPECIFY WEB SITE: _______)

91. OTHER (Specify: _____)

98. DON’T KNOW

99. REFUSED

[IF R2:2-99 DID NOT SEEK HELP OR INFORMATION OR R4:3-99 DID NOT CONTACT POISON CONTROL CENTER, ASK R5]

R5. In the past year, did you contact a poison control center for information or help related to a poisoning?

1. YES

2. NO

98. DON’T KNOW

99. REFUSED

[IF R4:1-2 OR R5:1 RESPONDENT CONTACTED POISON CONTROL CENTER, ASK R6]

R6. If a poison control center had not been available, what would you have done?

[RECORD RESPONDENT ANSWER EXACTLY]

98. DON’T KNOW

99. REFUSED

[ASK ALL RESPONDENTS]

R7. What telephone number would you use to contact a poison control center? [DO NOT READ, WAIT FOR RESPONSE]

1. 1-800-222-1222

2. OTHER 800 OR 888 NUMBER (Specify: __________)

3. OTHER 800 or 888 NUMBER, not specified

4. OTHER NUMBER, NOT 800 (Specify: __________)

5. OTHER NUMBER, NOT 800, not specified

6. 911

98. DON’T KNOW

99. REFUSED

[IF R7 NOT PUNCH 1, DID NOT NAME 1-800-222-1222, ASK]

R8. If you needed to contact a poison control center immediately, where would you look for the telephone number? [DO NOT READ / CODE ALL THAT APPLY]

1. POISON PREVENTION MATERIALS/MAGNET/STICKERS

2. TELEPHONE BOOK

3. 411/DIRECTORY ASSISTANCE

4. 911

5. PROGRAMMED IN MY CELLULAR PHONE

6. HRSA WEB SITE

7. POISON CONTROL CENTER WEB SITE

8. GOOGLE/YAHOO/SEARCH ENGINE

9. OTHER INTERNET OR ONLINE/SPECIFY: _____

10. OTHER/SPECIFY: _____

98 DON’T KNOW

99 REFUSED

[IF R8:1 WOULD CALL 1-800-222-1222 TO CONTACT A POISON CONTROL CENTER, ASK]

R9. How did you learn about 1-800-222-1222? [DO NOT READ/CODE ALL THAT APPLY]

1. LOCAL POISON CONTROL CENTER

2. PUBLIC SERVICE ANNOUNCEMENT/TV/RADIO

3. BROCHURE/MAGNET/STICKERS

4. POSTER

5. NEWSPAPER ARTICLE/MAGAZINE ARTICLE

6. NEWSPAPER ADVERTISEMENT

7. OUTDOOR ADVERTISING/BILLBOARD/BUS ADVERTISEMENT

8. TELEPHONE BOOK

9. 411/INFORMATION/DIRECTOR ASSISTANCE

10. DOCTOR/NURSE/HEALTH PROFESSIONAL

11. PHARMACIST/PHARMACY

12. WORD OF MOUTH/RELATIVE/FRIEND/COWORKERS

13. DAYCARE/SCHOOL/TEACHER

14. HRSA WEB SITE

15. POISON CONTROL CENTER WEB SITE

16. GOOGLE/YAHOO/SEARCH ENGINE

17. OTHER ADVERTISING/SPECIFY: ______

18. OTHER INTERNET OR ONLINE/SPECIFY: _____

91 OTHER/Specify: ____

98 DON’T KNOW

99 REFUSED

[IF R9:1-6 ADVERTISING AND MATERIALS, ASK]

R10. Where did you (see/receive) the material that had information about 1-800-222-1222? [DO NOT READ/CODE ALL THAT APPLY]

1. POISON CENTER / POISON CONTROL CENTER

2. DOCTOR/NURSE/HEALTH PRACTITIONER/OFFICE

3. PHARMACIST/PHARMACY

4. FIRE DEPARTMENT

5. POLICE DEPARTMENT

6. STORE

7. LIBRARY

8. HOSPITAL/EMERGENCY ROOM

9. RELATIVE/SPOUSE/PARENT/SIBLING

10. FRIEND/NEIGHBOR/COWORKER

11. DAYCARE/SCHOOL/TEACHER

12. COMMUNITY EVENT

13. HRSA WEBSITE

14. POISON CENTER WEB SITE

15. GOOGLE/YAHOO/SEARCH ENGINE

16. OTHER INTERNET OR ONLINE/SPECIFY: _____

91 OTHER/Specify: _____

98 DON’T KNOW

99 REFUSED

[ASK ALL]

R11. Do you have a cellular or wireless telephone?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

[IF R10:1 YES, OWN WIRELESS TELEPHONE, ASK]

R12. Do you have a poison control center number programmed in that telephone?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

[ASK ALL RESPONDENTS]

R13. Do you have a poison control center number posted in your home?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

[ASK ALL RESPONDENTS]

INTERVIEWER: Now, I would like to ask you some questions about poison control centers. Please answer based on what you know. If you do not know the answer, please tell me and we’ll move on to the next question.

R14. To the best of your knowledge… [ROTATE]

1 is there a single poison control center that serves the entire nation OR

2 are there multiple poison control centers that serve local areas?

98 Don’t know

99 REFUSED

R15. When are poison control centers open to respond to your call? [RANDOMIZE]

1. 24 hours a day, 7 days per week, 365 days a year

2. Monday through Friday, 9am to 5pm

3. Weekends only OR

98 Don’t know

99 REFUSED

R16. Who answers calls to poison control centers? [ROTATE]

1 Expert medical professionals

2 Trained volunteers OR

98 Don’t know

99 REFUSED

R17. If you do not speak English, can a poison control center still help you? [ROTATE]

1. Yes

2. No

98. Don’t know

99. REFUSED

R18. When you call a poison control center about a person who may have been poisoned, how much does it cost to receive information? [ROTATE]

1 Nothing, the call is free

2 A maximum of $25 (twenty-five dollars) OR

98. Don’t know

99. REFUSED

R19. When you call a poison control center, what other organizations or individuals have access to the information you provided? [RANDOMIZE, CHECK ALL THAT APPLY]

1. No one, it is kept confidential

2. Your health care provider

3. Your Insurance company

4. Law enforcement

5. Social services

98. DON’T KNOW

99. REFUSED

R20. Who do you think uses poison control services? Please select all that apply [RANDOMIZE / ACCEPT MULTIPLE RESPONSES]

1. Anyone/ Everyone

2. Law Enforcement Officers

3. Health Care Providers

4. Individuals who care for young children

5. Someone else [SPECIFY: _____]

6. NONE OF THE ABOVE

98 DON’T KNOW

99 REFUSED

R21 INTRO Now, just a few questions about you and your household.

R21. [READ IF NECESSARY] Are you male or female?

1. MALE

2. FEMALE

98 DON’T KNOW

99 REFUSED

R22. How old are you? Are you… [READ EACH CATEGORY]

1. 18-24

2. 25-34

3. 35-44

4. 45-54

5. 55-64

6. Age 65 or older

98 DON’T KNOW

99 REFUSED

R23. What is the highest grade or level of school you have completed? [DO NOT READ, CODE ONLY ONE RESPONSE]

1. NO SCHOOLING OR GRADES 1-8

2. SOME HIGH SCHOOL OR GRADES 9-11

3. GRADE 12, HIGH SCHOOL DIPLOMA, OR GED

4. VOCATION/TECHNICAL SCHOOL OR SOME COLLEGE, BUT NO BACHELOR’S DEGREE

5. BACHELOR’S DEGREE, B.A. OR B.S.

6. MORE THAN A BACHELOR’S DEGREE, POST-GRADUATE COURSES, M.D., PhD, LAW SCHOOL, ETC.

98 DON’T KNOW

99 REFUSED

[IF R23:1-3 HIGH SCHOOL DIPLOMA, EQUIVALENT OR LESS, ASK]

R24. Do you have a high school diploma or its equivalent, a GED?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

R25. Are you of Spanish, Hispanic, or Latino origin?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

R26. How would you describe your race? You may choose more than one. [RANDOMIZE, READ CHOICES, CODE ALL THAT APPLY.]

1. White

2. Black or African-American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Pacific Islander

98 DON’T KNOW

99 REFUSED

Now I have just a few questions about your household.

R27. Do any people under age 18 live in this household?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

R28. Do any people age 5 or younger live in this household?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

[IF R28:1 YES ASK]

R29. Are you a parent or guardian of any of these children age 5 and younger?

1. YES

2. NO

98 DON’T KNOW

99 REFUSED

R30. Which of the following best describes your health insurance coverage? You may choose more than one. [RANDOMIZE 1-5, READ 6 LAST, ACCEPT MULTIPLE RESPONSES]

1. Health insurance offered through your employer or union

2. Health insurance purchased yourself

3. Medicare

4. Medicaid

5. Health savings account, or HSA

6. No health insurance coverage

91. Something else (SPECIFY: ______)

98 DON’T KNOW

99 REFUSED

R31. What was the total income of all persons in your household over the past year, including salaries or other earnings, interest, retirement, and so on for all household members? Was it... [READ IN ORDER UNTIL RESPONSE CHOSEN]

1. Less than $25,000

2. $25,000 to $50,000

3. $50,001 to $75,000

4. $75,001 to $100,000

5. $100,001 to $150,000

6. $150,001 or more

98 DON’T KNOW

99 REFUSED

R32. What is your zip code? [RECORD]

ZIP CODE __ __ __ __ __

THANK Those are all the questions I have for you. Thank you very much for your time. I would like to give you a telephone number in case you are interested in receiving more information about poison prevention or the ways that poison control centers can help in a poison emergency. The number you can call is 1-800-222-1222. This number works from any place in the country and connects you to a local poison control center where health care professionals and other poison experts provide treatment advice about poisonings and poison prevention information 24 hours a day, every day of the year. There is no cost for the service. It is free and confidential. Translation services are available in over 160 languages.

Public Burden Statement:

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.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-49, Rockville, MD 20857.