QID Childhood Injury and Adult Occupational Injury Questionn

NATIONAL

AGRICULTURAL

STATISTICS

SERVICE

U.S. Department of Agriculture

Rm. 5905, South Building

1400 Independence Avenue, S.W.

Washington, D.C. 20250-2000

202-690-8141

Childhood Injury and

Adult Occupational Injury

Questionnaire

Form Approved:

O.M.B. Number 0535-0235

Approval Expires: mm/dd/yyy

Project Code 915

(Phone Script used for 2008 survey– This survey was conducted

totally by Phone Enumerators. Pre-survey letters were sent to the

respondents, notifying them of our upcoming calls.

An updated questionnaire will be provided, prior to the 2014 data collection.) QID: 110916

National

Please make corrections to name, address and Zip Code, if necessary.

Intro 1	Hello, my name is . I am working with the National Agricultural Statistics Service on behalf of the Center for Disease Control and Prevention. We are interested in learning more about injuries that occur on farms. We are asking farm/ranch families for information about their operations, as well as information on injuries that occurred on the farm/ranch in 2008. This will take about 10 minutes.
	The information you provide will be held strictly CONFIDENTIAL. Your cooperation is VOLUNTARY, and you may refuse to answer any question. This information will be combined with others to help identify common patterns of injuries on farms and to develop injury prevention and health promotion programs nationwide. Would you help us by answering these questions?

	YES - [Continue with Intro 2]
	NO - I assure you that everything you tell us will be kept confidential. Your answers are very important to us even if you did not have a youth on your farm, or did not have an injury on your farm in 2008. This project will be used to identify how often injuries occur on farms, and what the common patterns are for these injuries. The information will help identify programs for preventing these injuries in the future. Your cooperation will benefit all minority farm/ranch families. Would you please consider helping us? YES - [Continue with Intro 2] NO - I’m sorry to have bothered you. Thank you for your time. Says not a farm - [Continue with Intro 1a] Does not speak English

Intro 1a	Please answer the following question(s) for the total acres you (Name on label) operate.
	Did you grow any crops or cut hay in 2008? Yes - [Go to Intro 2] No - [Continue]
	Is any of the land in this operation cropland? Yes - [Go to Intro 2] No - [Continue] (Including idle cropland and cropland in government programs such as CRP, etc.)
	In 2008, did you have any whole grains, oilseeds, Yes - [Go to Intro 2] No - [Continue] or hay stored on this operation?
	Do you have facilities for storing whole grains or oilseeds? Yes - [Go to Intro 2] No - [Continue]
	Do you own or raise any livestock or poultry? Yes - [Go to Intro 2] No - [Go to Conclusion]

Intro 2
May I please speak with the adult female of the household?
01 Yes 02 Not available -- When would be a good time to call back?		Respondent
03 Spouse will give information
04 No adult female in household 05 Non-farm residence/Business address (Go to Operation Summary)
Please verify name and mailing address of this operation. Make corrections (Including the correct operation name) on the label and continue. [Check if name and address are verified]

How many people live in your household INCLUDING yourself, and EXCLUDING temporary visitors?
How many of the people living in your household are under the age of 20? (If 0, Skip to Operation Summary, question 1, page 7)
Where do the youth in your household most often go when they need medical attention? Do they go to a doctor’s office, a clinic, an emergency room, an urgent care center, or to some other place? 01 Doctor’s Office 05 Some other place 02 Clinic 77 Don’t know 03 Emergency Room 99 Refused 04 Urgent Care Center
What kind of health practitioner do the youth in your household usually see, a doctor, a nurse, a nurse practitioner (CNP), a physician’s assistant (PA), or someone else? 01 Doctor 05 Someone else 02 Nurse 77 Don’t know 03 Certified Nurse Practitioner 99 Refused 04 Physician’s Assistant
The last time any youth (under 20 years of age) in your household received professional medical attention, who paid the majority of the cost? Was it... 01 Paid out of pocket 06 Billed, did not pay 02 Medicare/Medicaid 07 Workers’ Compensation 03 Public Clinic No Charge 08 Other (Specify: _________________________________) 04 Employer paid health plan 77 Don’t know 05 Individual health plan (self/family) 99 Refused
HOUSEHOLD SUMMARY
1. Respondent’s Gender? 01 Male 02 Female
2. What was your age on your last birthday?
3. How many years of schooling have you completed?
4. What is the highest education level you have achieved? (Check ONLY ONE) 01 Less than high school 07 Doctorate 02 High School Diploma 08 Professional - MD, JD, DDS, etc. 03 Associates, two-year Junior College degree 09 Other (Specify _______________________) 04 Vocational/Technical School 77 Don’t know 05 Bachelor’s Degree 99 Refused 06 Master’s Degree
5. Have/Has (you/the farm operator) ever been told by a doctor, nurse, or other health professional that (you/they) had asthma? 01 Yes 77 Don’t Know [Go to Question 13] 03 No [Go to Question 13] 99 Refused [Go to Question 13] 6. How old (were you/was the farm operator) when asthma was diagnosed? Age ___________________________________ 97 Age 10 or younger but don’t know exact age 99 Don’t Know/Refused 7. Do you/Does the farm operator still have asthma 01 Yes 77 Don’t Know [Go to Question 13] 03 No [Go to Question 13] 99 Refused [Go to Question 13] 8. Have you/was the farm operator) ever told by a doctor, nurse, or other health professional that (your/their) asthma was related to (your/their) work on the farm? 01 Yes 77 Don’t Know 03 No 99 Refused 9. Did (you/the farm operator) have one or more asthma attacks requiring the use of an inhaler or other medical treatment in the last 12 months? 01 Yes 77 Don’t Know [Go to Question 13] 03 No [Go to Question 13] 99 Refused [Go to Question 13] 10. Did any such asthma attack occur while doing farm work? 01 Yes 77 Don’t Know 03 No 99 Refused 11. Did (you/the farm operator) have a serious asthma attack that required an emergency room visit, hospitalization, or other professional medical attention in the last 12 months? 01 Yes 77 Don’t Know [Go to Question 13] 03 No [Go to Question 13] 99 Refused [Go to Question 13] 12. Did any such asthma attack occur while doing farm work? 01 Yes 77 Don’t Know 03 No 99 Refused
13. What is your marital status? (Please check ONLY ONE) 01 Married 05 Married, but apart 99 Refused 02 Widowed 06 Single 03 Divorced 07 Single, living with partner 04 Separated 77 Don’t know Enumerator Note: If Married (01) or Single, living with partner (07) are marked, complete questions 14 through 17. Otherwise, go to Youth Summary, question 1.
14. Gender of spouse/partner? 01 Male 02 Female
15. What was your spouse’s/partner’s age on his/her last birthday?
16. How many years of schooling has your spouse/partner completed?
17. What is the highest level of education your spouse/partner has achieved? (Please check only one.) 01 Less than high school 07 Doctorate 02 High School Diploma 08 Professional - MD, JD, DDS, etc. 03 Associates, two-year Junior College degree 09 Other (Specify _______________________) 04 Vocational/Technical School 77 Don’t know 05 Bachelor’s Degree 99 Refused 06 Master’s Degree

YOUTH SUMMARY

Enumerator Note: Ask the following questions for each person under the age of 20 living within the household. Should match the number reported in Intro 2, question 4. Report information for up to 10 youth.
Now I would like to ask you some questions about each of the people living in your household under the age of 20, starting with the oldest.
1. Gender? 01 Male 02 Female
2. What was his/her age on his/her last birthday?
3. How many years of schooling has he/she completed?
4. Did he/she work on the farm or ranch in 2008? 01 Yes 03 No
5. Did he/she ride a horse, either for work or for recreation on the farm or ranch anytime in 2008? 01 Yes 03 No
6. Did he/she drive an all-terrain vehicle, either for work or for recreation on the farm or ranch anytime in 2008? 01 Yes 03 No
7. Did he/she operate a tractor on the farm or ranch anytime in 2008? 01 Yes 03 No
Has he/she ever been diagnosed as having asthma by a health professional? 01 Yes 03 No [Go to Operation Summary] 77 Don’t know [Go to Operation Summary] 99 Refuse [Go to Operation Summary]
Did he/she have one or more asthma attacks requiring the use of an inhaler or other medical treatment in 2008? 01 Yes 03 No [Go to Operation Summary] 77 Don’t know [Go to Operation Summary] 99 Refuse [Go to Operation Summary]
10. Did any such asthma attack occur while doing farm work? 01 Yes 03 No 77 Don’t know 99 Refuse
11. Did he/she have a serious asthma attack that required an emergency room visit, hospitalization, or other professional medical attention in 2008? 01 Yes 03 No [Go to Operation Summary] 77 Don’t know [Go to Operation Summary] 99 Refuse [Go to Operation Summary]
12. Did any such asthma attack occur while doing farm work? 01 Yes 03 No 77 Don’t know 99 Refuse

Enumerator Note: Ask the following questions if children under the age of 8 are living within the household.

13. Is there a completely enclosed, fenced off play area on your farm for children?

01 Yes 03 No 77 Don’t know 99 Refuse

14. Do you have access to licensed, off-farm child care?

01 Yes 03 No [Go to Operation Summary] 77 Don’t know 99 Refuse

15. How often do you utilize this service?

01 Never 77 Don’t know

02 Less than 1 month per year 99 Refuse

03 1 - 3 months per year

04 More than 3 months per year

OPERATION SUMMARY
Next, I have a few questions about your farm or ranch operation.
1. Is this a full-time or part-time operation? 01 Full-time 02 Part-time
2. When hiring farm workers, do you require them to have any type of formal training (e.g., tractor or machinery operator certification, pesticide application certification, commercial drivers license)? 01 Yes (Specify: ) 03 No 05 Never hires workers [Go to question 4]
3. Do you provide any safety training for workers on your farm, excluding unsupervised on-the-job training (e.g., training on the proper operation of tools, equipment, or machinery; pesticide safety training, training on proper lifting techniques, training on safe work practices)? 01 Yes (Specify: ) 03 No
Enumerator Note: Questions 4 through 12 should only be asked if the Adult Injury Section will also be completed.
Tractor overturns result in severe injuries on farms each year. In order to design programs to reduce the risk of tractor overturns, we need basic information about farm tractors.
4 How many agricultural tractors, excluding lawn tractors, were owned or leased by this operation in 2008? Do not Include antique or similar collectable tractors not used for production purposes on the farm or ranch. (If 0, go to question 8)
5. How many of these agricultural tractors were equipped with a Roll-Over Protective Structure (ROPS) or a ROPS cab?
6……..Of the total number of tractors reported, how many were diesel?
7……..What is the total number of hours that (you/farm operator) personally operated ALL of the diesel tractors in the last 12 months?
01 Less than 100 hours 02 100 – 499 hours 03 500 – 1,000 hours 04 More than 1,000 hours 77 Don’t know 99 Refused
All terrain vehicles, ATV’s, are a common cause of injury on farms. In order to accurately assess the nature of these injuries, we need information about ATV’s used on the farm.
8. How many ATV’s were used on this farm (including recreation use) in 2008? (If 0, go to question 13)
9. How many of these ATV’s were used for work purposes in 2008?
Beginning with the newest ATV and working back to the oldest ATV:
10. What make is the ATV? Enter code from below
01 Argo 02 Arctic Cat 03 Bombardier 04 Honda 05 John Deere	06 John Deere 07 Kawasaki 08 Polaris 09 Recreatives Industries 10 Yamaha	11 Suzuki 12 Yamaha 13 Other
11. What was the size of the ATV? 01 200 cc and smaller 04 401 cc and larger 02 201 - 300 cc 77 Don’t know 03 301 - 400 cc 99 Refused
12. On average, how often would you say this ATV was used in 2008? 01 10 or more times a month 04 Less than once a month 02 5 to 9 times a month 77 Don’t know 03 1 to 4 times a month 99 Refused
Enumerator Note: Repeat questions 8 through 12 for up to 5 ATV’s
13. During 2008, approximately how many people under the age of 20 were hired to work on the farm or ranch, (excluding household members and contract labor)? If zero, go to question 15 Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown
14. For each of these workers, please tell me their age and gender and whether or not they operated a tractor, an ATV, or rode a horse on the farm or ranch as part of their job. Enumerator Note: Repeat question for up to 20 workers.

Worker	Age	Gender		Operated a tractor		Operated an ATV		Rode a horse
a.		Male	Female	Yes	No	Yes	No	Yes	No
b.		Male	Female	Yes	No	Yes	No	Yes	No
c.		Male	Female	Yes	No	Yes	No	Yes	No
d.		Male	Female	Yes	No	Yes	No	Yes	No
e.		Male	Female	Yes	No	Yes	No	Yes	No
f.		Male	Female	Yes	No	Yes	No	Yes	No
g.		Male	Female	Yes	No	Yes	No	Yes	No
h.		Male	Female	Yes	No	Yes	No	Yes	No
i.		Male	Female	Yes	No	Yes	No	Yes	No
j.		Male	Female	Yes	No	Yes	No	Yes	No
k.		Male	Female	Yes	No	Yes	No	Yes	No
l.		Male	Female	Yes	No	Yes	No	Yes	No
m.		Male	Female	Yes	No	Yes	No	Yes	No
n.		Male	Female	Yes	No	Yes	No	Yes	No
o.		Male	Female	Yes	No	Yes	No	Yes	No
p.		Male	Female	Yes	No	Yes	No	Yes	No
q.		Male	Female	Yes	No	Yes	No	Yes	No
r.		Male	Female	Yes	No	Yes	No	Yes	No
s.		Male	Female	Yes	No	Yes	No	Yes	No
t.		Male	Female	Yes	No	Yes	No	Yes	No

We’ve already discussed household youth and youth hired to work on your farm. Next, we’d like to ask you about other visitors to your farm and whether or not they may have helped out with work on the farm.

15. Approximately how many relatives under the age of 20 visited the farm during 2008 (excluding hired workers and youth already mentioned)? Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown
16. How many of these relatives performed unpaid work on your farm during 2008? Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown
17. Excluding hired workers, relatives, or household members, approximately how many other people under the age of 20 visited the farm during 2008, for example, friends of your children? Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown

YOUTH INJURY SUMMARY
Next I’m going to ask you some questions about any injuries to anyone under the age of 20 that occurred on the farm or ranch during 2008.
1. During 2008, did anyone on the farm under the age of 20 experience any injuries which required at least 4 hours of restricted activity or required professional medical attention? These injuries would include those resulting from farm work, chores or recreation on the farm or ranch, or in the home. 01 Yes 03 No [Go to Conclusion if Respondent has not been selected for Adult Injury Questionnaire. If Respondent has been selected to receive Adult Injury questions, Go to Adult Injury Summary, question 1]
2. How many child/adolescent injuries of this type occurred on the farm or ranch during 2008?
Now we would like to ask you some questions about each of these injuries.
Enumerator Note: If respondent does not want to provide the first name of the injured person, please assign a unique identifier (such as “Child A”) which will also be used when completing the narrative.
3. Starting with the most recent child/adolescent injury, what is the first name of the injured person?
4. What was the age of this person at the time of the injury?
5. What is the gender of this person? 01 Male 02 Female
6. What is the injured person’s relationship to the farm or ranch? 01 Self 05 Worker 02 Child/Step-Child 06 Boarder 03 Spouse 07 Other (Specify: ) (e.g. friend, visiting school youth) 04 Other Relative
7. Is the injured person Hispanic or Latino, such as Mexican, Cuban, or Puerto Rican, regardless of race? 01 Yes 03 No
8. What is the injured person’s race? (Please check  ONE OR MORE) 01 American Indian or Alaska Native Tribe (Specify: _______________ ) 04 Native Hawaiian or other Pacific Islander 02 Asian 05 White 03 Black or African American
9. In what month did this injury occur? 01 January 07 July 02 February 08 August 03 March 09 September 04 April 10 October 05 May 11 November 06 June 12 December
Enumerator Note: If the injured person is over the age of 16 and resides in the household, ask to speak to that person. However, if this respondent has been selected for the Adult Injury Questionnaire, do not ask to switch. If the injured person is not part of this household, is not available, or is under 16, continue interviewing the respondent.
10. Did the injured person live on the farm or ranch? 01 Yes [Go to question 12] 03 No
11. Was the injured person visiting the farm or ranch at the time of the injury? 01 Yes 03 No
12. Did this injury occur while completing work or doing chores on the farm or ranch? 01 Yes 03 No [Go to question 16]
13. At the time of the injury, how many hours per week did the injured person typically work on the farm or ranch? 01 0 - 10 04 31 - 40 02 11 - 20 05 More than 40 hours 03 21 - 30
14. Was a supervisor in the immediate area at the time of the injury? 01 Yes 03 No
15. How much experience did the injured person have in performing the task being completed at the time of the injury? 01 None 05 1 week to 4 weeks 02 Less than 4 hours 06 1 month to 12 months 03 4 to 8 hours 07 More than 1 year 04 1 to 7 days
16. Where on the farm or ranch did the injury occur? 01 Crop Field or Hayfield , Orchard, Nursery 08 Public Roadway 02 Pasture 09 In the House 03 In the Farm Yard 10 Garage 04 Grain Storage/Silo 11 House Yard 05 Farm Outbuilding 12 Driveway/Sidewalk 06 Barn 13 Outdoors, General 07 Farm Roadway 14 Other (Specify: )
17. Now I would like for you to describe in as much detail as possible how the injury occurred. Include where the injury occurred, what tasks were being completed, what equipment was being used or materials being handled, and any other factors you think might be important. Enumerator Note: PROBE FOR DETAIL Enumerator Note: If injury resulted in a fatality, you may terminate the interview unless the respondent wishes to continue. Probe for details.

Interviewer Checklist Location Barn, field, house Specific Activity Equipment & Tools Powered-On/Off Using/Cleaning Materials Handled Ag Chemicals, Fertilizer, etc. Other Factors
	NIOSH USE ONLY:
	SOURCE EVENT
	2ND SOURCE E-CODE

18. What part of the body was injured? (Please check all that apply) 01 Head/Skull 07 Arm 02 Face 08 Hand/Wrist/Fingers 03 Neck 09 Leg 04 Shoulder/Chest/Back 10 Foot/Ankle/Toes 05 Abdomen 11 Internal Injuries 06 Pelvic Region 12 Other (Specify: )
19. What type of injury occurred to the (specify body part)? (Please check all that apply) 01 Scrape/Abrasion 08 Traumatic Rupture 02 Bruise/Contusion 09 Crushed/Mangled 03 Sprain/Strain/Torn Ligament 10 Loss of Body Part/Amputation 04 Broken Bone/Fracture 11 Nerve Injury 05 Dislocation 12 Burn/Blister/Scald 06 Cut/Laceration 13 Concussion, Traumatic Brain Injury 07 Puncture/Stab/Jab 14 Other (Specify: )
20. How long were the injured person’s normal activities restricted as a result of this injury? 01 No restriction 05 14 days to less than 1 month 02 Less than 1 day 06 1 month to less than 3 months 03 1 day to less than 7 days 07 3 months or more 04 7 days to less than 14 days
21. Did the injury result in a permanent disability? 01 Yes 03 No
22. On a scale of 1 to 5, how would you rate the overall seriousness of this injury, with 1 being minor and 5 being life-threatening? 01 Minor 04 Severe 77 Don’t know 02 Moderate 05 Life-threatening 99 Refused 03 Serious 06 Fatal (Enum. Note: If respondent does not wish to continue, leave note and terminate interview.)
23. Did this injury require medical attention? 01 Yes 03 No [Go to question 27]
24. Where did the injured person receive medical treatment for this injury? 01 Doctor’s Office or Clinic 07 Urgent Care Center 02 Hospital Emergency Department 08 At the Scene 03 Non-emergency Clinic at Hospital 09 Other (Specify: ) 04 Public Clinic 77 Don’t know 05 Dentist 99 Refused 06 Chiropractor
25. Did this injury require admission to a hospital? 01 Yes 03 No [Go to question 27]
26. How long was the hospitalization? Number of Days
27. Was a tractor involved in the injury? 01 Yes 03 No [Go to question 34] Enumerator Note: If narrative suggests a tractor was involved, please probe.
28. Was the injured person operating the tractor when the injury occurred? 01 Yes [Go to question 30] 03 No
29. Was the injured person riding on the tractor as a passenger, working near the tractor, or was the injured person a bystander? 01 Riding as a Passenger 77 Don’t know 02 Working Near the Tractor [Go to question 33] 99 Refused 03 Bystander [Go to question 33] 04 Other (Specify: )
30. Did the tractor have a seatbelt? 01 Yes 77 Don’t know 03 No [Go to question 32] 99 Refused
31. Was the injured person wearing a seat belt? 01 Yes 77 Don’t know 03 No 99 Refused
32. Did the tractor have a roll-over protective structure (ROPS)? 01 Yes 77 Don’t know 03 No 99 Refused
33. When the injury happened, which of the following best describes what the injured person was doing? 01 Tilling 07 Spreading Manure 02 Planting 08 Using the Tractor as a Stationary Power Unit 03 Harvesting 09 Repairing the Tractor 04 Adjusting/Hitching Load/Equipment 10 Mounting/Dismounting the Tractor 05 Traveling to or from a Field 11 Using the Tractor for Recreation 06 Applying Chemicals 12 Other (Specify: )
34. Was an all terrain vehicle, for example an ATV or 4-wheeler, involved in the injury? 01 Yes 03 No [Go to question 41] Enumerator Note: If narrative suggests an ATV was involved, please probe.
35. Was the injured person wearing a helmet at the time of the injury? 01 Yes 03 No
36. Was the injured person operating the ATV at the time of the injury? 01 Yes 03 No
37. When the injury occurred, which of the following best describes what the injured person was doing at the time of the injury? 01 Making Adjustments or Repairs 02 Using the Vehicle for Recreation 03 Using the Vehicle for General Transportation not related to Farm Work 04 Using the Vehicle for Farm Work 05 Other (Specify: )
38. Was it a 3-wheel, 4-wheel or more than 4-wheel ATV? 01 3-wheel 02 4-wheel 03 More than 4-wheel
39. What was the engine size of the ATV? 01 200 cc and smaller 04 401 cc and larger 02 201 - 300 cc 77 Don’t know 03 301 - 400 cc 99 Refused
40. Had the injured person completed a training class for operating an ATV? 01 Yes 03 No
41. Was a horse involved in the injury? 01 Yes 03 No [Go to question 51] Enumerator Note: If narrative suggests a horse was involved, please probe.
42. Was the injured person riding a horse at the time of the injury? 01 Yes 03 No [Go to question 48]
43. When the injury occurred, would you say the horse was standing, walking, trotting, galloping, jumping or something else? 01 Standing 04 Galloping 02 Walking 05 Jumping 03 Trotting 06 Other (Specify: )
44. Was the injured person thrown from the horse? 01 Yes 03 No
45. Was the injured person wearing a helmet when the injury occurred? 01 Yes 03 No
46. Was a saddle being used at the time of the injury? 01 Yes 03 No [Go to question 48]
47. Was the saddle adjusted to the size of the rider? 01 Yes 03 No
48. What was the injured person doing at the time of the injury? 01 Leading/Loading 06 Assisting another Rider 02 Shoeing 07 Feeding/Loading 03 Saddling 08 Using Horse for Farm/Ranch Work 04 Grooming 09 Other (Specify: ) 05 Cleaning Stalls
49. How did the injury occur, was the injured person bitten, kicked, stepped on, pinned, or something else? 01 Bitten 04 Pinned 02 Kicked 05 Other (Specify: ) 03 Stepped on
50. What type of horse was involved in the injury? Was it a pony, a draft horse, other horse, mule or some other type of horse? 01 Pony 05 Other (Specify: _______________________) 02 Draft Horse 77 Don’t know 03 Other Horse 99 Refused 04 Mule
51. Other than a horse, were any other livestock or animals involved in the accident? 01 Yes 03 No [Go to question 55] Enumerator Note: If narrative suggests other animals were involved, please probe.
52. What type of livestock or other animals were involved in the injury? 01 Adult Cattle 08 Cat 02 Calf 09 Rabbit 03 Pig/Hog 10 Rodent 04 Poultry 11 Snake 05 Sheep 12 Insect/Spider 06 Goat 13 Other (Specify: ) 07 Dog
53. Did this injury occur in the barn, in a parlor, pasture, in a holding area, or someplace else? 01 Barn 04 Holding Area 02 Parlor 05 Other (Specify: ) 03 Pasture
54. What was the injured person doing at the time of the injury? 01 Feeding 10 Treating Animal for Injury/Illness 02 Milking 11 Helping Animal with Birthing Process 03 Herding/Moving Livestock 12 Trimming Hooves/Shoeing 04 Cleaning Pen 13 Shearing 05 Breeding 14 Butchering 06 Castrating 15 De-Horning 07 Branding 16 Vaccinating 08 Riding 17 General Children’s Play 09 A Bystander 18 Other (Specify: )
55. Did the injury involve a fall? (Excluding events already described that involved horses, ATV’s, and/or tractors.) 01 Yes 03 No [Go to question 59] Enumerator Note: If narrative suggests a fall was involved, please probe.
56. What was the injured person doing when the fall occurred? 01 Sitting 06 Going Up or Down Stairs/Ladder 02 Standing 07 General Children’s Play 03 Walking 08 Mounting/Dismounting Equipment 04 Running 09 Other (Specify: ) 05 Climbing Object other than Ladder (Specify: )
57. Onto what type of surface did the injured person fall? 01 Concrete 05 Building Floor 02 Gravel 06 Water-Filled Ditch 03 Dirt 07 Other (Specify: ) 04 Wood Floor (e.g., deck)
58. Where the injured person fell, what was the surface like at the time? 01 Dry, Hard Surface 05 Loose Surface (e.g., gravel, sand, loose hay) 02 Icy 06 Surface not a contributing factor 03 Wet 07 Other (Specify: )
59. Enumerator Note: Was more than 1 injury reported in question 2, Youth Injury Summary? 01 Yes [Repeat questions 3 through 59 and continue until information has been collected for the four most recent injuries.] 03 No
60. Was Respondent selected for Adult Injury Survey? 01 Yes [Go to Adult Injury Summary, page 18.] 03 No [Go to Conclusion]

ADULT INJURY SECTION
Next I would like to ask you some questions regarding individuals 20 years of age or older who may work on your farm. Include those workers you hired directly to work on your farm. Please do not include contract laborers such as farm labor contract workers, custom harvesting service workers, construction service workers, etc.
1. During 2008, how many household members age 20 or older, including yourself, did work on the farm or ranch? Enumerator Note: if respondent indicated that this is a non-farm residence/business, go to question 2.
2. During 2008, approximately how many people age 20 or older were hired to work on the farm or ranch (excluding household members and contract labor)? Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown
3. During 2008, approximately how many people age 20 or older visited the farm and did farm work, excluding hired workers (for example, your relatives or friends)? Enumerator Note: use ‘7777' for refusal or ‘9999' for unknown
Next, I’m going to ask you some questions about any work-related injuries to anyone age 20 or older that occurred on the farm or ranch during 2008. Include those workers you hired directly to work on your farm/ranch. Please do not include injuries incurred by these adults through recreation or non-work related activities or contract workers, custom harvesting service workers, construction service workers, etc.
4. During 2008, did anyone on the farm age 20 or older experience any work-related injuries which required at least 4 hours of restricted activity or required professional medical attention? 01 Yes 03 No [Go to Conclusion]
5. How many adult injuries of this type occurred on the farm or ranch during 2008?
Now we would like to ask you some questions about each of these injuries. Enumerator Note: Please collect information for the 2 most recent injuries.
If respondent does not want to provide the name of the injured person, please assign a unique identifier (such as “Adult A”) which will also be used when completing the narrative.
6. Starting with the most recent adult injury, what is the first name of the injured person?
7. What was the age of this person at the time of the injury?
8. What is the gender of this person? 01 Male 02 Female
9. What is the injured person’s relationship to the farm? 01 Self 05 Worker 02 Child/Step-Child 06 Boarder 03 Spouse 10 Other (Specify: ) 04 Other Relative
10. Is the injured person Hispanic or Latino, such as Mexican, Cuban, or Puerto Rican, regardless of race? 01 Yes 03 No
11. What is the injured person’s race? (Please check  ONE OR MORE) 01 American Indian or Alaska Native Tribe (Specify: _______________ ) 04 Native Hawaiian or other Pacific Islander 02 Asian 05 White 03 Black or African American
12. In what month did this injury occur? 01 January 07 July 02 February 08 August 03 March 09 September 04 April 10 October 05 May 11 November 06 June 12 December
13. Where on the farm did the injury occur? 01 Crop Field, Orchard, Nursery 08 Public Roadway 02 Pasture 09 In the House 03 In the Farm Yard 10 Garage 04 Grain Storage/Silo 11 House Yard 05 Farm Outbuilding 12 Driveway/Sidewalk 06 Barn 13 Outdoors, General 07 Farm Roadway 14 Other (Specify: )

14. Now I would like for you to describe in as much detail as possible how the injury occurred. Include where the injury occurred, what tasks were being completed, what equipment was being used or materials being handled, and any other factors you think might be important.

Enumerator Note: If injury resulted in a fatality, you may terminate the interview unless the respondent wishes to continue.

Probe for details.

Interviewer Checklist Location Barn, field, house Specific Activity Equipment & Tools Powered-On/Off Using/Cleaning Materials Handled Ag Chemicals, Fertilizer, etc. Other Factors
	NIOSH USE ONLY:
	SOURCE EVENT
	2ND SOURCE E-CODE

15. What part of the body was injured? (Please check all that apply) 01 Head/Skull 07 Arm 02 Face 08 Hand/Wrist/Fingers 03 Neck 09 Leg 04 Shoulder/Chest/Back 10 Foot/Ankle/Toes 05 Abdomen 11 Internal Injuries 06 Pelvic Region 12 Other (Specify: )
16. What type of injury occurred to the (specify body part)? (Please check all that apply) 01 Scrape/Abrasion 08 Traumatic Rupture 02 Bruise/Contusion 09 Crushed/Mangled 03 Sprain/Strain/Torn Ligament 10 Loss of Body Part/Amputation 04 Broken Bone/Fracture 11 Nerve Injury 05 Dislocation 12 Burn/Blister/Scald 06 Cut/laceration 13 Concussion, Traumatic Brain Injury 07 Puncture/Stab/Jab 14 Other (Specify: )
17. How long were the injured person’s normal activities restricted as a result of this injury? 01 No restriction 05 14 days to less than 1 month 02 Less than 1 day 06 1 month to less than 3 months 03 1 day to less than 7 days 07 3 months or more 04 7 days to less than 14 days
18. Did the injury result in a permanent disability? 01 Yes 03 No
19. On a scale of 1 to 5, how would you rate the overall seriousness of this injury, with 1 being minor and 5 being life-threatening? 01 Minor 04 Severe 77 Don’t know 02 Moderate 05 Life-threatening 99 Refused 03 Serious 06 Fatal (Enum. Note: If respondent does not wish to continue, leave note and terminate interview.)
20. Did this injury require medical attention? 01 Yes 03 No [Go to question 24]
21. Where did the injured person initially receive treatment for this injury? 01 Doctor’s Office or Clinic 05 Dentist 09 Other (Specify: ) 02 Hospital Emergency Department 06 Chiropractor 77 Don’t know 03 Non-emergency Clinic at Hospital 07 Urgent Care Center 99 Refused 04 Public Clinic 08 At the Scene
22. Did this injury require admission to a hospital? 01 Yes 03 No [Go to question 24]
23. How long was the hospitalization? Number of Days
24. Enumerator Note: Was more than 1 injury reported in question 2, Adult Injury Summary? 01 Yes, [Repeat questions 3 through 24 and collect information for the second most recent injury.] 03 No [Go to Conclusion]

CONCLUSION

That is all the questions I have for your today. Thank you very much for your time. We hope this information will help us learn more about how to prevent injuries on farms and ranches.

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