Appendix D Barriers to Reporting Questionnaire

Appendix D

Data collection instrument

(Barriers to reporting questionnaire)

NIOSH Barriers to Reporting Questionnaire

Interviewer: record before interview

Reported date of ER visit

Date fill for [date – 3 months]________________

Consent

Hello. My name is (interviewer name). I am calling for the Centers for Disease Control and Prevention. We are gathering information to learn how people decide whether or not to report a workplace injury. You were chosen for this study from emergency department records. I understand that on ____/____/____ you were treated in the emergency room at ________________________________ hospital. Is this correct?

IF YES: Interviewer note: continue with introduction.

IF NO: Were you recently treated on a different day in a hospital emergency room?

IF STILL NO: Thank you for your time.

IF YES: What day was that? ____/____/____

IF DATE IS WITHIN 21 DAYS OF RECORDED DATE: Continue

with introduction.

IF DATE IS GREATER THAN 21 DAYS FROM RECORDED DATE: Thank you for your time.

In the last few weeks you should have received a letter explaining this research study and how we will protect your privacy. I am required to tell you four things that were in this letter:

(1) Taking part in this study involves a small risk to your privacy, but we take many steps to prevent that risk.

(2) There is no direct benefit for taking part in this study.

(3) Your answers to our questions will be kept private to the extent allowed by law. Your name, address, or anything else that could identify you will never be associated with the information you give.

(4) If you have questions about the study or you feel you were harmed, you may call Larry Jackson, the CDC project officer, at 304-285-5980 or Mark Toraason, the chair of the Institutional Review Board, at 513-533-8591.

This interview takes about 30 minutes. You do not have to answer any questions you do not want to. You can end the call at any time. Would you please help us by answering some questions?

IF YES: Interviewer note: Begin interview.

IF NO: : I assure you that everything you tell us will be kept private and will only be used to study how people decide whether or not to report a workplace injury. Your participation is very important. Would you please reconsider helping us?

Qualifying section

QS1) Did you go to the Emergency Room, or ER, because you needed care for an injury, such as a broken bone, a burn, a sprain, a cut, electrical shock, or carbon monoxide poisoning?

YES 1

NO 2 (End Interview)

REFUSED -7 (End Interview)

DON’T KNOW -8

QS2) Was your injury the result of a single, sudden event? [Interviewer note: aggravations of previous injuries are acceptable if aggravating event was single and sudden and did not happen slowly over time]

YES 1

NO 2 (End Interview)

REFUSED -7 (End Interview)

DON’T KNOW -8 (End Interview)

QS3) Were you employed on the day of your injury? (Interviewer note: If on vacation the week before injury but working the day of the injury, count this as a work-related injury.)

YES 1 (Go to QS4)

NO 2

REFUSED -7

DON’T KNOW -8

QS3a. [IF QS3=NO] Were you employed at any time during the 7 days before your injury?

YES 1

NO 2 (End Interview )

REFUSED -7

DON’T KNOW -8

QS4) At the moment you were injured, were you working for pay?

YES 1 (Follow questions for Work-Related Injury (WR))

NO 2 (Follow questions for Not Work-Related (NWR))

REFUSED -7

DON’T KNOW -8

QS5) Your employer is the person or company who pays you. On the day you were injured, did you have more than one employer?

YES 1 (See instruction below)

NO 2 (See instruction below)

REFUSED -7

DON’T KNOW -8

[If Yes and WR] From this point on, all of my questions will refer to job where your injury happened. I will call this “the job where you were injured” (&&)

[If Yes and NWR] From this point on, all of my questions will refer to job where you work the most hours per week. I will call this “your main job.” (&&)

[If No, refer only to “your job.”] (&&)

(**Note: the above wording will be filled in where && is located in questions**)

QS6) People who are self-employed may work in their own business, as a partner in a partnership, as an independent contractor in a trade, or as an owner of a farm. Were you self-employed in &&?

YES 1 (End Interview)

NO 2

REFUSED -7

DON’T KNOW -8

QS7) Some workers are day laborers who wait at a place where employers pick up people to work for a day. Were you working as a day laborer in &&?

YES 1 (End Interview)

NO 2

REFUSED -7

DON’T KNOW -8

QS8) [If WR] At the moment you were injured, were you working on a farm or ranch?

YES 1 (End Interview)

NO 2

REFUSED -7

DON’T KNOW -8

QS9) [If WR] After your injury did you return to work with the same employer where the injury occurred, even for a short time?

YES 1 (Go to QS10)

NO 2 (Go to QS9a)

REFUSED -7 (End interview)

DON’T KNOW -8 (End interview)

QS9a) [If QS9=No] Is this because your injury is preventing you from returning to work?

YES 1 (End Interview)

NO 2 (Go to QS13)

REFUSED -7 (End interview)

DON’T KNOW -8 (End interview)

QS10) [If WR] Did you return to work with your employer on the same day as your ER visit?

YES 1 (Go to QS14)

NO 2 (Go to QS13)

REFUSED -7 (Go to QS13)

DON’T KNOW -8 (Go to QS13)

QS11) [If NWR] At the time of your injury, was && on a farm or ranch?

YES 1 (End Interview)

NO 2

REFUSED -7

DON’T KNOW -8

QS12) [If NWR] Have you returned to work at && you had before your injury?

YES 1 (Go to QS13)

NO 2 (Go to QS12a)

REFUSED -7 (End interview)

DON’T KNOW -8 (End interview)

QS12a) [If QS12=No] Is this because your injury is preventing you from returning to work?

YES 1 (End Interview)

NO 2 (Go to QS13)

REFUSED -7 (End interview)

DON’T KNOW -8 (End interview)

QS13) Calendar days refer both to days that you would normally work and to days that you normally would not work, for example, weekends and days off. After your injury, how many calendar days passed before you returned to work?

_________[ALLOW 0-90]

REFUSED -7 (End Interview)

DON’T KNOW -8

QS13a) Was it….

None 1

1-3 days 2

4-10 days 3

11 or more days 4

REFUSED -7 (End Interview)

DON’T KNOW - 8 (End Interview)

QS13b) When you returned to work did you actually feel well enough to go back to work?

Yes 1

No 2 (Go to QS13d)

* Programming note: If (QS13 >3 or QS13a = 3 or 4) and QS13b = 2, then End Interview

[If (QS13=0 or 1 or QS13a=1) and QS13b=Yes, go to QS14]

[If QS13b=YES]

QS13c) Some people may feel well enough to work before they actually go back to work. After your injury, how many calendar days passed until you actually felt well enough to start working again?

|___|___|___|Days (Go to QS14)

REFUSED -7

DON’T KNOW -8

* Programming note: If QS13c > 3 then End Interview

[If QS13c=REF or DK]

QS13ci. Was it….

None, you felt well enough on the same day that you were injured

1 (Go to QS14)

1-3 days 2 (Go to QS14)

4-10 days 3 (End Interview)

11 or more days 4 (End Interview)

REFUSED -7 (End Interview)

DON’T KNOW -8 (End Interview)

[If QS13b=NO]

QS13d) I understand you went back to work before you felt well enough. After your injury, how many calendar days passed until you actually felt well enough to start working again?

|___|___|___|Days

Still don’t feel well enough -6 (End Interview)

REFUSED -7 (End Interview)

DON’T KNOW -8 (End Interview)

*Programming note: If QS13d>3, end interview

QS13di) Was it….

1-3 days 2

4-10 days 3 (End Interview)

11 or more days 4 (End Interview)

REFUSED -7 (End Interview)

DON’T KNOW -8 (End Interview)

* Programming note: If Self employed, Emp1=YES, then End Section

QS14) Which of these terms would you like me to use to refer to the person who directly oversaw your work at &&: [Response will fill in where “TBA” is currently noted –must choose one or end interview]

Boss 1

Supervisor 2

Manager 3

Foreman 4

Other, please specify ___________________ 5

QS15) Would you please describe the injury that caused you to go to the ER for treatment? [Prompts: Where were you when your injury happened? What parts of your body were injured? What kind of an injury did you have? What were you doing when your injury happened? {if WR} Was this part of your normal job duties? Were you using any safety equipment or personal protective equipment?]

ER Reporting

ER_Intro Now I am going to ask you some questions about your visit to the ER on [DATE]. These questions will ask you to remember events or conversations that happened while you were there.

ERR1) When you arrived at the ER, were you awake and aware of what was going on around you?

YES 1 (Go to ERR2)

NO 2 (END SECTION)

ERR2) [If ERR1=Yes] Were you able to communicate with the people working in the ER?

YES 1 (Go to ERR3)

NO 2 (END SECTION)

RR3) [If WR] Did you tell anyone working in the ER that your injury happened at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

ERR4) While you were checking into the ER, were you asked if your injury happened at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

NOT APPLICABLE -10

ERR5) When you were being examined in the ER, were you asked if your injury happened at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

NOT APPLICABLE -10

ERR6) [If WR] Did anyone at work tell you NOT to tell ER staff that your injury happened at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

Reporting a Work-Related Injury – ONLY WR INJURIES.

RWRI_Intro Now I am going to ask you some questions about telling people at work about your injury.

RWRI1. Many employers give their workers instructions about who they should tell if they are hurt or become sick from something at work. Before you were injured, were you given instructions on who to tell?

YES 1 (Go to RWRI1a)

NO 2 (Go to RWRI1b)

REFUSED -7 (Go to RWRI1b)

DON’T KNOW -8 (Go to RWRI1b)

DON’T REMEMBER -9 (Go to RWRI1b)

RWRI1a. [If RWRI1=YES] Which of the following best describes who you were supposed to tell first?

Your TBA… …………… 1

A union representative …… ..…………… 2

Someone else at work ……………………………………………………………… 3

What was your relationship to this person?__________________

NO ONE …………………………………………………………………………………… 4

REFUSED ………………………………………………………………………………… -7

DON’T KNOW ……………………………………………………………………………-8

* Programming note: If respondent answers RWRI1a, skip RWRI1b.

RWRI1b. [If RWRI1 NOT EQUAL YES]Which of the following best describes who you thought you were supposed to tell?

Your TBA …………… 1

A union representative …………….……… ….…… 2

Someone else at work ……………………………………………………………… 3

What was your relationship to this person?__________________

NO ONE …………………………………………………………………………………… 4

REFUSED ………………………………………………………………………………… -7

DON’T KNOW ……………………………………………………………………………-8

* Programming note: Use response from above to fill in the blanks [person supposed to tell] below

RWRI2. Did you tell [person supposed to tell] that your injury happened at work?

YES 1 (Go to RWRI2a)

NO 2 (Go to RWRI3)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If RWRI2=YES]

RWRI2a. What was the most important reason you told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If RWRI2=YES, Go to question RWRI4

RWRI3. Did [person supposed to tell] find out about your injury some other way?

YES 1 (Go to RWRI3a)

NO 2 (Go to RWRI3b)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If RWRI3=YES]

RWRI3a. If they had NOT found out some other way, would you have told [person supposed to tell] that your injury happened at work?

YES 1 (Go to RWRI3a1)

NO 2 (Go to RWRI3a2)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If RWRI3a=YES]

RWRI3a1. What was the most important reason you would have told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If RWRI3a=YES, go to question RWRI4

[If RWRI3a=NO]

RWRI3a2. What was the most important reason you would NOT have told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If RWRI3a=NO, Goto RWRI4

[If RWRI3=NO]

RWRI3b. What was the most important reason you did not tell [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

RWRI4. Were there people or groups who wanted you to tell your TBA about your work injury?

YES 1 (Go to RWRI4a)

NO 2 (Go to RWRI5)

REFUSED -7 (Go to RWRI5)

DON’T KNOW -8 (Go to RWRI5)

DON’T REMEMBER -9 (Go to RWRI5)

[If RWRI4=YES]

RWRI4a. Who were these people or groups?

RWRI5. Were there people or groups who did NOT want you to tell your TBA about your work injury?

YES 1 (Go to RWRI5a)

NO 2 (Go to programming notes)

REFUSED -7 (Go to programming notes)

DON’T KNOW -8 (Go to programming notes)

DON’T REMEMBER -9 (Go to programming notes)

[If RWRI5=YES]

RWRI5a. Who were these people or groups?

* Programming note: If RWRI2=YES, Go to RWRI6

* Programming note: If RWRI2=NO, Go to RWRI10

* Programming note: If RWRI3a = NO, Go to RWRI10

* Programming note: If RWRI3a = YES, End section, Go to section MCSR

RWRI6. Were there any changes in your jobsite because you reported your injury to your TBA?

YES 1 (Go to RWRI6a)

NO 2 (Go to RWRI7)

REFUSED -7 (Go to RWRI7)

DON’T KNOW -8 (Go to RWRI7)

DON’T REMEMBER -9 (Go to RWRI7)

[If RWRI6=YES]

RWRI6a. What changes were made?

RWRI7. Were there any changes in your job because your reported your injury to your TBA?

YES 1 (Go to RWRI7a)

NO 2 (Go to RWRI8)

REFUSED -7 (Go to RWRI8)

DON’T KNOW -8 (Go to RWRI8)

DON’T REMEMBER -9 (Go to RWRI8)

[If RWRI7=YES]

RWRI7a. What changes were made?

RWRI8. Was it difficult to report your work injury to your TBA?

YES 1 (Go to RWRI8a)

NO 2 (Go to RWRI9)

REFUSED -7 (Go to RWRI9)

DON’T KNOW -8 (Go to RWRI9)

DON’T REMEMBER -9 (Go to RWRI9)

[If RWRI8=YES]

RWRI8a. Why was reporting your injury to your TBA difficult?

RWRI9. Do you have anything to add about your experience reporting your injury? (End Section, Go to MCSR))

* Programming note: If RWRI2=YES, End Section, go to section MCSR

RWRI10. Do you have anything else to add about your decision NOT to report your injury?

Medical Coverage and State of Recovery

MCSR_Intro Now I am going to ask you some questions about paying for your ER visit and about any care you have needed for your injury since your ER visit on ___/___/___.

MCSR1) Have you heard about worker’s compensation, also called worker’s comp?

YES 1 (Go to MCSR1a)

NO 2 (Go to MCSR2)

REFUSED -7 (Go to MCSR2)

DON’T KNOW -8 (Go to MCSR2)

MCSR1a) On the day of your injury, were you covered by workers compensation at [&&]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

MCSR2) Health insurance is one way that people pay medical bills. Health insurance may be purchased on your own, through a family member or partner, through an employer or union, or through a government program. On the day of your injury, did you have health insurance?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

MCSR3) Now I’m going to read you a list of ways people can pay medical bills. Please tell me if you asked the ER to bill one of these. [If respondent indicates they have more than one insurer, ask “Which of these do you think will pay the larger part of the bill?”]

Your health insurance 1 [If had health insurance]

Yourself out-of-pocket 2

Worker’s Compensation, also called “Worker’s Comp” 3 [[If WR] and [MCSR1 NOT EQUAL 2 OR MCSR1a NOT EQUAL 2]]

Your employer directly 4

Another source 5

(Specify)_____________________________

No one 6

REFUSED -7

DON’T KNOW -8

MCSR4) Sometimes patients need additional care after going to the ER. This can include surgery, overnight stays in the hospital, visits to doctors, nurses, or physician’s assistants, or therapy. After being seen on [DATE OF ER VISIT] have you HAD any additional care for this injury?

YES 1 (Go to MCSR4a)

NO 2 (Go to MCSR5)

REFUSED -7 (Go to MCSR5)

DON’T KNOW -8 (Go to MCSR5)

MCSR4a) [If MCSR4=Yes] Please describe the additional care you received. [Probes: Anything else?]

MCSR5) Other than follow-up or check-up appointments and any medications, do you think you WILL NEED additional care for your injury? (If asked, medications do not qualify as additional care.)

YES 1 (Go to MCSR5a)

NO 2 (Go to MCSR6 or MCSR7)

REFUSED -7 (Go to MCSR6 or MCSR7)

DON’T KNOW -8 (Go to MCSR6 or MCSR7)

MCSR5a) [If MCSR5=Yes] Do you think that the cost of care will keep you from getting that care?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

MCSR6_Intro [If WR] Now I am going to ask you a few questions about going back to work after your injury. / [If NWR] Even though your injury did not happen at work, I am interested in how && was affected by your injury.

[Refer to initial screening question on return to work for skip pattern.]

MCSR6) [If returned to same employer] On the first day you went back to work at &&, were you physically able to do your normal job tasks without restrictions?

YES 1 (Go to MCSR9)

NO 2 (Go to MCSR6a)

REFUSED -7 (Go to MCSR6a)

DON’T KNOW -8 (Go to MCSR6a)

MCSR6a) [If MCSR6=No] Were you assigned job tasks other than your normal job tasks?

YES 1 (Go to MCSR6a1)

NO 2 (Go to MCSR6a2)

REFUSED -7 (Go to MCSR9)

DON’T KNOW -8 (Go to MCSR9)

MCSR6a1) [If MCSR6a=Yes] Were you assigned light duty or tasks that were easier for you to do with your injury?

YES 1 (Go to MCSR9)

NO 2 (Go to MCSR9)

REFUSED -7 (Go to MCSR9)

DON’T KNOW -8 (Go to MCSR9)

MCSR6a2) [If MCSR6a=No] Were your normal job tasks changed so that you could perform them with your injury?

YES 1 (Go to MCSR9)

NO 2 (Go to MCSR9)

REFUSED -7 (Go to MCSR9)

DON’T KNOW -8 (Go to MCSR9)

MCSR7) [If NOT returned to same employer] As a reminder, your employer is the person or company who pays you. You said before that you had NOT returned to work with &&. Which of the following best describes why you have not returned?

You were let go from your job 1 (Skip TPB questions)

You quit 2 (Skip TPB questions)

Another reason 3

(specify)_______________________________________

REFUSED -7 (Skip TPB questions)

DON’T KNOW -8 (Skip TPB questions)

MCSR8) Are you physically able to do the same type of job tasks you did before your injury?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

MCSR9_Intro Now I am going to ask you about your ability to do certain activities outside of work. Please tell me how much you are limited in doing these activities as of today. When answering, think about limitations that are related to your general health as well as limitations resulting from your injury.

MCSR9) Does your health limit you in doing vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports?

Not at all 1

Very little 2

Somewhat 3

Quite a lot 4

Cannot do the activity 5

REFUSED -7

DON’T KNOW -8

MCSR10) Are you able to run or jog for two miles?

Without any difficulty 1

With a little difficulty 2

With some difficulty 3

With much difficulty 4

Cannot do the activity 5

REFUSED -7

DON’T KNOW -8

MCSR11) Are you able to do yard work like raking leaves, weeding, or pushing a lawn mower?

Without any difficulty 1

With a little difficulty 2

With some difficulty 3

With much difficulty 4

Cannot do the activity 5

REFUSED -7

DON’T KNOW -8

MCSR12) Are you able to climb up 5 flights of stairs?

Without any difficulty 1

With a little difficulty 2

With some difficulty 3

With much difficulty 4

Cannot do the activity 5

REFUSED -7

DON’T KNOW -8

MCSR13) Are you able to use your hands, such as for turning faucets, using kitchen gadgets, or sewing?

Without any difficulty 1

With a little difficulty 2

With some difficulty 3

With much difficulty 4

Cannot do the activity 5

REFUSED -7

DON’T KNOW -8

MCSR14) [If MCSR9, MCSR10, MCSR11, MCSR12, OR MCSR13 NOT EQUAL 1] You reported that you have some difficulty doing physical activities. Is this difficulty in any way related to your injury?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Occupational Data

OD_Intro This next set of questions are about && and refer to the seven days before your injury happened. Although some questions may not seem to apply to you, I have to ask all questions as written.

OD1) Your employer is the company, organization, or person who pays you. Please think about all people who were paid by your employer. When you were injured, did your employer have 11 or more employees?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD2) Medical providers may be doctors, nurses, physician’s assistants, or people trained in first aid. At &&, were there medical providers on the work site?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD3) At the time of your injury, were you a member of a union at &&?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD4) At &&, did you supervise other employees?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD5) Were you performing contract work for another company or organization in &&?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD6) Some people are in temporary jobs that last for a limited time. Was && temporary?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD7) Some people are in a pool of workers who are called to work as needed. These people are sometimes referred to as on-call workers. Were you an on-call worker in &&?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD8) In what you considered to be a normal work week at &&, how many hours did you work?

|___|___|___| Hours (Go to OD11)

REFUSED -7 (Go to OD9)

DON’T KNOW -8 (Go to OD8a)

OD8a) [If OD8=DK], Even though you don’t know exactly how many hours a week you worked in && during a normal work week, would you say you worked less than 35 hours a week, or 35 or more hours a week?

<35 hours 1

≥35 hours 2

REFUSED -7

DON’T KNOW -8

* Programming note: Skip OD9, OD10, and OD10a if NWR (QS4 = 2).

OD9. [If WR] Other than the time you may have taken to go to the ER, did you take any time off work to recover from your injury or to go to medical appointments related to your injury?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD10. Paid time off may include sick, vacation, or personal leave. When your injury happened, did you have any paid time off available to you?

YES 1 (If OD9=YES, Go to OD10a)

NO 2 (Go to OD11)

REFUSED -7 (Go to OD11)

DON’T KNOW -8 (Go to OD11)

OD10a. [IF OD9=YES and OD10=YES] Did you use any of your paid time off to cover the time you took off work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD10b. [IF OD9=YES] Did you use any unpaid time off to cover the time you took off work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD11) On the day of your injury, had you worked for your employer for more than one year?

YES 1 (Go to OD11a)

NO 2 (Go to OD11b)

REFUSED -7 (Go to OD12)

DON’T KNOW -8 (Go to OD12)

OD11a) [If OD11=Yes] How many years had you worked for your employer? If you had a break in your employment, tell me the total number of years worked for your employer.

|___|___|Years |___|___| Months [Include months only if offered by respondent]

REFUSED -7

DON’T KNOW -8

OD11b) [If OD11=No] How many months had you worked for your employer?

|___|___| Months |___|___|Days [Include days only if offered by respondent]

REFUSED -7

DON’T KNOW -8

OD12) On the day BEFORE your injury, how secure did you feel about keeping your job?

Very secure 1

Somewhat secure 2

Neither secure nor insecure 3

Somewhat insecure 4

Very insecure 5

REFUSED -7

DON’T KNOW -8

OD13) [If Union, OD3=YES] If you are injured at work, does your union encourage you to report your injury to your TBA?

YES 1 (Go to OD14)

NO 2 (Go to OD13a)

REFUSED -7 (Go to OD14)

DON’T KNOW -8( Go to OD14)

OD13a) [IF OD13=NO] Does your union discourage you from reporting injuries to your TBA?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD14) Does your employer have a policy that workers who are injured while working should be tested for drugs?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

OD15) At the time of your injury, were there any rewards at &&, such as cash, parties, or gift cards, available to people or teams who did not have an injury?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

TPB Questions (Refer to Page 13, MCSR7 for persons designated to skip this section)

TPB_Intro I am going to describe a possible situation at work and ask you to imagine what you would do if it really happened. Here is the situation. Suppose that sometime in the next week you were injured while doing your normal work duties at &&. Your TBA is not around and does not know that you have been injured. You go to the ER for treatment, expecting that this injury will require you take three days off from work.

TPB1) When you are at the ER, a nurse asks you where your injury happened. How likely are you to tell them it happened at work?

Very likely 1 (Go to TPB1a)

Somewhat likely 2 (Go to TPB1a)

Neither likely nor unlikely 3 (Go to TPB1a)

Somewhat unlikely 4 (Go to TPB1a)

Very unlikely 5 (Go to TPB1a)

REFUSED -7 (Go to TPB2)

DON’T KNOW -8 (Go to TPB2)

TPB1a) [If not refused or don’t know] Why would you be [insert answer from above] to tell the nurse that your injury happened at work? [Probe: any other reason?]

______________________________________________________________________________

REFUSED -7

DON’T KNOW -8

TPB2) How likely is it that you would tell your TBA your injury happened at work?

Very likely 1 (Go to TPB2a)

Somewhat likely 2 (Go to TPB2a)

Neither likely nor unlikely 3 (Go to TPB2a)

Somewhat unlikely 4 (Go to TPB2a)

Very unlikely 5 (Go to TPB2a)

REFUSED -7 (End section)

DON’T KNOW -8 (End section)

TPB2a) [If not refused or don’t know] Why would you be [insert answer from above] to tell your TBA that your injury happened at work? [Probe: any other reason?]

______________________________________________________________________________

REFUSED -7

DON’T KNOW -8

TPB3) Overall, would you say that telling your TBA your injury happened at work is…

Very important 1

Somewhat important 2

Neither important nor unimportant 3

Somewhat unimportant 4

Very unimportant 5

REFUSED -7

DON’T KNOW -8

TPB4) Would you say that telling your TBA your injury happened at work is harmful, beneficial, both harmful and beneficial, or neither harmful or beneficial?

Harmful 1 (Go to TPB4a)

Beneficial 2 (Go to TPB4a)

Both harmful and beneficial 3 (Go to TPB5)

Neither harmful nor beneficial……………………………………… 4 (Go to TPB5)

REFUSED -7 (Go to TPB5)

DON’T KNOW -8 (Go to TPB5)

TPB4a) [IF HARMFUL OR BENEFICIAL] Would you say it is very [harmful/beneficial] or somewhat [harmful/beneficial]?

Very 1

Somewhat 2

REFUSED -7

DON’T KNOW -8

TPB5_Intro Now I am going to read you some questions about the opinions of other people. Please tell me how strongly you agree or disagree with the following statements.

TPB5) Other people at work would encourage you to report your injury to your TBA.

Strongly agree 1

Somewhat agree 2

Neither agree nor disagree 3

Somewhat disagree 4

Strongly disagree 5

REFUSED -7

DON’T KNOW -8

TPB6) Other people at work would want you to report your injury to your TBA.

Strongly agree 1

Somewhat agree 2

Neither agree nor disagree 3

Somewhat disagree 4

Strongly disagree 5

REFUSED -7

DON’T KNOW -8

TPB7) People who are important to you would encourage you to report your injury to your TBA.

Strongly agree 1

Somewhat agree 2

Neither agree nor disagree 3

Somewhat disagree 4

Strongly disagree 5

REFUSED -7

DON’T KNOW -8

TPB8) People who are important to you would want you to report your injury to your TBA.

Strongly agree 1

Somewhat agree 2

Neither agree nor disagree 3

Somewhat disagree 4

Strongly disagree 5

REFUSED -7

DON’T KNOW -8

TPB9) Tell me how confident you are that you could report the work injury to your TBA if you wanted to? Are you…

Extremely confident 1

Very confident 2

Somewhat confident 3

A little confident 4

Not at all confident 5

REFUSED -7

DON’T KNOW -8

Demographic & Sensitive Occupational Information

DSOI_Intro Finally, I would like to ask you a few questions about yourself. Please remember that all information will only be used for research and will be held confidential.

DSOI1) Which of the following best describes who you worked for in &&: (Interviewer note: if respondent answers 1 & 2, choose response 1)

A business owned by your family 1

A private company or organization 2

Federal, State, or Local Government 3

OTHER 5

_______________________________

REFUSED -7

DON’T KNOW -8

DSOI2) We are interested in learning about the type of business or organization you were working for when you were injured. Please describe what this company or organization did, or what products it made.

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

DSOI3) In which state was && located?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

[If refused] We will use the state to help us classify the industry you were working in. We will not contact your employer for any reason.

DSOI4) Your employer is the person or company who pays you. What was the name of the employer you were working for in &&?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

[If refused] We will use the name to classify the industry you were working in. We will not contact your employer for any reason.

DSOI5) What was your job title at &&?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

[If hesitates or DK] What was your job title? Examples could be a high school teacher, a residential construction worker, or a registered nurse.

DSOI6) What were your primary job duties in &&?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

DSOI7) Please tell me which of the following best describes the highest level of education you completed:

Did not complete high school 1

High School Diploma or GED 2

Some College 3

College Degree 4

Graduate Degree 5

Professional School Degree 6

OTHER 7

(Specify)______________________________________

REFUSED -7

DON’T KNOW -8

DSOI8) What year were you born?

|___|___|___|___|

REFUSED -7

DON’T KNOW -8

DSOI9) Are you of Hispanic or Latino origin or descent?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If Don’t Know or Hesitates] “This includes people from, or descended from, Spain, Mexico, Puerto Rico, Cuba, The Dominican Republic, or from Central or South America. Hispanics or Latinos may be of any race.”

DSOI10) Which of the following race or races describe you? (Select one or more)

White 1

Black or African-American 2

Asian 3

Native American or Alaska Native 4

Native Hawaiian or Pacific Islander 5

REFUSED -7

DON’T KNOW -8

DSOI11) Were you born in the United States or in a US territory? (US territories include Midway Islands, Puerto Rico, American Samoa, Virgin Islands, Federated States of Micronesia, Marshall Islands, Northern Mariana Island, Palau, and Guam.)

YES 1 (Go to DSOI12)

NO 2 (Go to DSOI11a)

REFUSED -7 (Go to DSOI12)

DON’T KNOW -8 (Go to DSOI12)

DSOI11a) [If DSOI11=No] What country were you born in?

________________________________________ (Go to DSOI11b)

REFUSED -7 (Go to DSOI11b)

DON’T KNOW -8 (Go to DSOI11b)

[If refused] We will only use the country of your birth for research.

DSOI12) We are interested in your total family income. Family income is your income PLUS the income of all family members living in your household. Please stop me when I read the category that best matches what your total family income was between January 20__ and December 20__:

1 Under $15,000?

2 Between 15,000 and 30,000?

3 Between 30,000 and 50,000?

4 Between 50,000 and 75,000?

5 Between 75,000 and 100,000?

6 Over 100,000?

-7 REFUSED

-8 DON’T KNOW

DSOI13) Including yourself, how many people live in your home?

|___|___| people

REFUSED -7

DON’T KNOW -8

______________________________________________________