Form QID Childhhood Injury and Adult Occupational Injury Question

24

Project 915 QID				OMB No. 0535-0235 Approval Expires 1/31/2012
	NATIONAL AGRICULTURAL STATISTICS SERVICE	CHILDHOOD INJURY AND ADULT OCCUPATIONAL INJURY QUESTIONNAIRE
U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 Email: [email protected]
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB number is 0535-0235. The time required to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Under Title 7 of the U.S. Code and CIPSEA (Public Law 107-347), facts about your operation are kept confidential and used only for statistical purposes in combination with similar reports from other producers. Response is voluntary.
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 farmers/ranchers for information about their operations, as well as information on injuries to youth that occurred on the farm/ranch in the last 12 months. 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 other’s 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 on 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 the last 12 months. 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 farm/ranch families. Would you please consider helping us?
			YES - [Continue on 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.
	a. Did you grow any crops or cut hay in the last 12 months?	Yes – [Go to Intro 2]	No – [Continue]
	b. Is any of the land in this operation cropland? (Including idle cropland and cropland in government programs such as CRP, etc.)	Yes – [Go to Intro 2]	No – [Continue]
	c. In the last 12 months did you have any whole grains, oilseeds, or hay stored on this operation?	Yes – [Go to Intro 2]	No – [Continue]
	d. Do you have facilities for storing whole grains or oilseeds?	Yes – [Go to Intro 2]	No – [Continue]
	e. Do you own or raise any livestock or poultry?	Yes – [Go to Intro 2]	No – [Go to Conclusion]

Intro 2
1. May I please speak with the adult female of the household?
01 Yes
02 Not available						Respondent
When would be a good time to call back?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
03 Spouse will give information
04 No adult female in household
05 Non-farm residence/business address (Go to Operation Summary)
2. Please verify name and mailing address of this operation. Make corrections (Including the correct operation name) on the label and continue. [Check box if name and address are verified] .
3. How many people live in your household (INCLUDING yourself, and EXCLUDING temporary visitors)?. . . .
4. How many of the people living in your household are under the age of 20? (If 0, Skip to Household Summary, question 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. 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
6. 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
7. 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 that 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 been 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 [Go to Question 13]
	03 No		99 Refused [Go to Question 13]
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		03 Female
15. What was your spouse’s/partner’s age on his/her last birthday?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16. How many years of schooling have 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. It 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 their last birthday?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. How many years of schooling has he/she completed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Did he/she work on the farm or ranch in the last 12 months?
01 Yes			03 No
5. Did he/she ride a horse, either for work or for recreation on the farm or ranch anytime in the last 12 months?
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 the last 12 months?
01 Yes			03 No
7. Did he/she operate a tractor on the farm or ranch anytime in the last 12 months?
01 Yes			03 No
8. Has he/she ever been diagnosed as having asthma by a health professional?
01 Yes				03 No [Go to question 13]
77 Don't know [Go to question 13]				99 Refuse [Go to question 13]
9. Did he/she 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 he/she 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	03 No				77 Don’t Know		99 Refused

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 Refused
14. Do you have access to licensed, off-farm child care?
01 Yes	03 No [Go to Operation Summary]			77 Don’t Know		99 Refused
15. How often do you utilize this service?
01 Never			04 More than 3 months per year
02 Less than 1 month per year			77 Don’t Know
03 1 – 3 months per year			99 Refused

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 driver's 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
Tractor overturns result in severe injuries on farms each year. In order to design programs to reduce the risk of tractor overturns, we need some basic information about your farm tractors
4. How many agricultural tractors, excluding lawn tractors, were owned or leased by this operation in the last 12 months? 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/the 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 77 More than 1,000 hours 99 Refused
All-terrain vehicles, also known as 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 your farm.
8. How many ATV’s were used on this farm (including recreation use) in the last 12 months? (If 0, go to question 13)
9. How many of these ATV’s were used for work purposes in the last 12 months?

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 Kawasaki 07 Polaris 08 Recreative Industries 09 Yamaha 10 Suzuki	11 Other

11. What was the size of the ATV?
01 200 cc and smaller 02 201 – 300 cc 03 301 – 400 cc	04 401 cc and larger 77 Don’t Know 99 Refused
12. On average, how often would you say this ATV was used in the last 12 months?
01 10 or more times a month 02 5 to 9 times a month 03 1 to 4 times a month		04 Less than once a month 77 Don’t Know 99 Refused
Enumerator Note: Repeat questions 10 through 12 for up to 5 ATV’s
13. During the last 12 months, 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 the last 12 months (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 the last 12 months?. . . . . . . . . . . . .
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 the last 12 months, 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 the last 12 months.
1. During the last 12 months, 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 youth injuries of this type occurred on the farm or ranch during the last 12 months?. . . . . . . .
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:_______________)
04 Other Relative				(e.g. friend, visiting school youth)
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 Specify tribe:_____________					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 DETAILS
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				07 1 month to less than 3 months
03 1 day to less than 7 days				09 3 months or more
04 7 days less than 14 days
21. Did the injury result in a permanent disability?
01 Yes
02 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 the 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	77 Jumping
03 Trotting	99 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 [Go to question 50]
03 No [Go to question 50]
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, 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 somewhere 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
02 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	04 Loose Surface (e.g., gravel, sand, loose hay)
02 Icy	05 Surface not a contributing factor
03 Wet	06 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 20.]
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. Including 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 the last 12 months, 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 the last 12 months, 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 the last 12 months, 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 the last 12 months. 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 the last 12 months, 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 the last 12 months?. . . . . . . . .
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 the 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 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		12 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 this 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 you 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.