Form 0920-0834 EMS Worker Notification Form

APPENDIX D

Form Approved

OMB No. 0920-0834

Exp. Date 12/31/2012

EMS Worker Injury and Illness Questionnaire

Interviewer instructions:

(1) Response choices and comments in italics are not to be read to the respondent.

(2) Sentences in bold type are to be read aloud to the respondent.

(3) Unless otherwise noted, all questions apply to the time of injury.

(4) If the respondent has already provided the information to a question say, “I know you’ve already told me this, but I have to ask each question as written.”

(5) Some questions have “Read categories” noted in parentheses after the question. For these questions, be sure to read each of the response choices aloud.

(6) Some questions have a response choice of “Don’t know.” Do not offer this choice. It is there for your use if the respondent identifies “don’t know” without prompting. If a respondent initially gives an uncertain response, the interview should probe once in an attempt to get a definitive answer.

EMS Injury and illness

April 2010

INTERVIEWER: FILL IN TASK # AND COMPLETE INFORMATION IN INTRODUCTION BEFORE STARTING INTERVIEW.

T ask No.: _______HEP_______

RECORD OF CALLS

Suggested Call-Back Time

Date	Day of Week	Time (Eastern)	Result		Day	Time
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
___/___/___	_______	___:___ am/pm	_______	_______		___:___ am/pm
Result codes:	B =Language barrier		N = Non-working number
	C = Completed		NA = No Answer
	CB = Call Back		R = Refusal
	I = Injury not work-related		T = Terminated
	LB = Line Busy		W = Wrong number
	M = Answering machine		X = Not an EMS worker

Comments (attempts to find correct phone number, reasons for refusal etc.) :________________ ______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Hello. May I speak with __________________________________________?

Hi. My name is ________________________________________________. I am working with the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration to study injuries and illnesses to people who perform emergency medical services work. In the last few weeks you should have received a letter explaining this research study and how we will protect your privacy if you participate in this study. You do not have to answer any questions you do not want to, and you can end the interview at any time. I understand that on ____/____/____ you were treated in ________________________________ hospital emergency department for an [injury/illness/exposure] that occurred at work. Is this correct?

IF YES: Continue with introduction.

IF NO: Were you treated on a different day in a hospital emergency department for an [injury/illness/exposure] that occurred at work? 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.

IF STILL NO: Thank you for your time.

I would like to ask you some questions about your [injury/illness/exposure]. Your participation is particularly important to us because you represent a number of workers who hold a similar job, but were not selected for an interview.

There is no direct benefit to you for participating in this study. The only risk to participating is a potential loss of privacy. Any information that you give us will be protected by the Privacy Act. Neither your name nor any personal information will be in records held by the Centers for Disease Control and Prevention or the National Highway Traffic Safety Administration. Data collected for this study are done so under the authority described in the Occupational Safety and Health Act of 1970.

The interview takes about 20 minutes to complete. Would you please help us by answering some questions?

IF YES: Thank you. [Interviewer to start the questionnaire.]

IF NO: I assure you that everything you tell us will be kept private and will only be used to study how to prevent [injuries/illnesses/exposures] on the job. Your participation is very important and will benefit workers providing emergency medical services. Would you please reconsider helping us?

IF YES: Thank you. [Interviewer to start the questionnaire.]

IF STILL NO: I understand that this may be a bad time. May I call back at another time?

IF YES: When is a good time for you? (Verify the date and time by repeating the information. Record the date and time of the call back on the calling log.)

IF NO: Thank you for your time.

I’d like to begin by getting some basic information about your job and your [injury/illness/exposure].

Screening questions

(1) When the [injury/illness/exposure] occurred, were you providing care to a patient?

A. Yes

B. No

(2) When the [injury/illness/exposure] occurred, were you on duty as an EMS worker, either paid or volunteer? (If asked, EMS worker = emergency medical services worker.)

A. Yes (SKIP TO Q5)

B. No

(3) When the [injury/illness/exposure] occurred were you on duty as a firefighter?

A. Yes (SKIP TO Q4)

B. No

IF RESPONSE IS “NO” TO Q1, Q2, AND Q3, END INTERVIEW

IF RESPONSE IS “YES” TO Q1, “NO” TO Q2, AND “YES” TO Q3, SKIP TO Q5.

IF RESPONSE IS “NO” TO Q1 AND Q2 AND “YES” TO Q3, END INTERVIEW

(4) In addition to the job you were doing at the time of injury, did you work as an EMS worker, either paid or volunteer?

A. Yes

B. No

IF RESPONSE IS “YES” TO Q1 AND “NO” TO Q2, Q3, AND Q4 END INTERVIEW

Injury details

(5) Were you treated in the emergency department on the same day your [injury/illness/exposure] occurred?

A. Yes (SKIP TO Q6)

B. No

C. Don’t know

(6) On what date did your [injury/illness/exposure] occur?

A. ____/____/____ (MM/DD/YYYY)

B. Unknown

(7) Based on a 24 hour clock, approximately what time did your [injury/illness/exposure] occur?

A. ___ ___: ___ ___

B. Unknown am

C. Unknown pm

D. Don’t know

(8) Approximately how many hours had you worked on your EMS shift before your [injury/illness/exposure] occurred? Please do not count “on call” hours when you were not working at your base station or on active EMS duty. (Hours worked at other jobs prior to the injury should not be counted. If a range of hours is given, record the midpoint.)

1. ___ ___

2. Don’t know

(9) After your [injury/illness/exposure], did you finish your work shift?

A. Yes

B. No

C. Don’t know

(10)Did your [injury/illness/exposure] occur while you were on a call or a run?

1. Yes

2. No (SKIP TO Q11)

3. Don’t know (SKIP TO Q11)

(11) Was this a 9-1-1 emergency call?

A. Yes

B. No

C. Don’t know

(12) Would you please describe, in your own words, how your [injury/illness/exposure] occurred?

_

If not included in description, prompt with these questions:

1. What was the nature of the [injury/illness/exposure]? For example, a cut to right finger or a bruise to left lower leg.

2. How did the [injury/illness/exposure] occur?

3. What specific task or activity were you engaged in at the time of the [injury/illness/exposure]?

4. Where did this happen? For example, inside base, on a highway, or in an ambulance.

5. Were other persons involved, such as co-workers?

6. What equipment, if any, were you using? This includes personal protective equipment.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Thank you for describing your [injury/illness/exposure]. I’m going to continue to ask you questions about your [injury/illness/exposure]. Some of these questions may repeat the information you’ve just given me, but I need to ask them as they appear in the questionnaire.

(13) What was the treating physician’s primary diagnosis of your [injury/illness/exposure]? (If the respondent states they do not know, ask “What do you think the primary diagnosis of your [injury/illness/exposure] was?”)

A. ___________________________________________________________________

B. Don’t know

(14) What other diagnoses resulted from your [injury/illness/exposure]?

A. ______________________________________________________________________

________________________________________________________________________________________________________________________________________________

B. None

(15) What body part, if any, was most affected by your [injury/illness/exposure]?

________________________________________________________

(16) Were there other parts of your body affected by your [injury/illness/exposure]?

A. Yes

B. No

C. Don’t know

IF RESPONSE IS “NO” OR “DON’T” KNOW”, SKIP TO Q18

(17) What other body parts were affected by your [injury/illness/exposure]?

A. _______________________________________________________________________

________________________________________________________________________

B. None

(18) Please describe the treatment you received in the emergency department for your [injury/illness/exposure].

__________________________________________________________________________________________________________________________________________________

Motor Vehicle Questions

(19) A motor vehicle incident includes incidents where the vehicle swerved, stopped suddenly, or overturned. It also includes collisions where you were struck by a vehicle or a vehicle struck an object, person, or animal. Did your [injury/illness/exposure] involve a motor vehicle incident?

A. Yes

B. No (SKIP TO EXPOSURE TO A HARMFUL SUBSTANCE SECTION)

C. Don’t know (SKIP TO EXPOSURE TO A HARMFUL SUBSTANCE SECTION)

(20) What type of vehicle were you riding in at the time of the incident? (Read categories.) A. Ambulance (SKIP TO Q24)

B. Fire truck (SKIP TO Q26)

C. EMS Motorcycle (SKIP TO Q23)

D. EMS vehicle other than an ambulance, fire truck or motorcycle. Please describe:_______________________________________________ (SKIP TO Q26)

E. Personal vehicle (SKIP TO Q26)

F. Not applicable, was not riding in a vehicle

(21) At the time of the incident, were you wearing high-visibility garments other than protective fire gear?

A. Yes

B. No

C. Don’t know

(22) At the time of the incident, were you wearing protective fire gear?

A. Yes (SKIP TO Q30)

B. No (SKIP TO Q30)

C. Don’t know (SKIP TO Q30)

(23) At the time of the incident, were you wearing a helmet?

A. Yes (SKIP TO Q27)

B. No (SKIP TO Q27)

C. Don’t know (SKIP TO Q27)

(24) Where in the ambulance were you at the time of the incident? (Read categories.)

A. The driver’s seat (SKIP TO Q27)

B. The passenger front seat (SKIP TO Q27)

C. The patient compartment

(25) Where were you in the patient compartment at the time of the injury? (Read categories.)

A. On the squad bench

B. In the attendant seat

C. In the CPR seat

D. Not on any seat

E. Other, please describe: ___________________________________________

F. Don’t know

(26) Were you wearing a seatbelt at the time of the incident?

A. Yes

B. No

C. Don’t know

(27) At the time of the incident, were emergency lights and/or sirens being used by the vehicle you were in?

A. Yes

B. No

C. Don’t know

(29) Tell me whether any of the following describe the incident.

A. Your vehicle struck another vehicle?	Yes No
B. Your vehicle was struck by another vehicle?	Yes No
C. Your vehicle struck a fixed object?	Yes No
D. Your vehicle rolled over?	Yes No
E. Your vehicle struck a person or animal?	Yes No

(30) Which of the following factors may have contributed to the incident? (Select all that apply)

A. Weather or road conditions? Please describe: __________________________________________	Yes No Don’t know
B. Lighting conditions? Please describe: ___________________________________________	Yes No Don’t know
C. A problem with the [ambulance/vehicle]? Please describe: ____________________________________	Yes No Don’t know

Exposure to a Potentially Harmful Substance Questions

(31) Did your [injury/illness/exposure] involve exposure to a potentially harmful substance, including body fluids, chemicals, and other hazardous materials? (Exposure to fire, smoke, or weather-related conditions, such as heat or cold, should not be included in this section.)

A. Yes

B. No (SKIP TO ASSAULT AND VIOLENCE SECTION)

C. Don’t know (SKIP TO ASSAULT AND VIOLENCE SECTION)

(32) What parts of your body were exposed to a potentially harmful substance? (Read categories.)

A. Eye?	Yes No
B. Mouth?	Yes No
C. Nose?	Yes No
D. Skin?	Yes No
E. Other parts of your body? Please describe: ____________________________________________________	Yes No
F. Don’t know	Yes No

(33) What potentially harmful substances were you exposed to? (Read categories.)

A. Blood?	Yes No
B. Respiratory secretions?	Yes No
C. Urine and/or feces?	Yes No
D. Vomit?	Yes No
E. Hazardous chemical waste?	Yes No
F. Other substances, including chemicals? Please describe: ____________________________________________________	Yes No
G. Don’t know	Yes No

(34) Now I am going ask about how your exposure occurred. Tell me yes or no for each question.

A. Were you spit on?	Yes No
B. Were you vomited on?	Yes No
C. Were you coughed on?	Yes No
D. Were you bitten by a person?	Yes No
E. Were you stuck by a needle?	Yes No
F. Was the exposure due to a container leaking or breaking? If yes, please describe the container: __________________________________________________	Yes No
G. Was the exposure due to tubing, a bag, or a pump leaking or breaking?	Yes No
H. Was the exposure due to contact with a contaminated surface?	Yes No
I. Were you exposed in some other way? If yes, please describe: ___________________________________________________	Yes No

(35)* Which of the following best describes the procedure you were performing when your [injury/exposure] occurred? (Read categories.)

A. I.V. line procedures, such as starting an I.V.

B. Blood sampling

C. Intramuscular injection

D. Intubation

E. CPR

F. Handling equipment or specimens

G. Disposing of a needle

H. Disposing of waste other than a needle

I. Other, please describe:____________________________________________________

(36) Which of the following were you wearing at the time of [injury/illness/exposure]? (Read categories.)

A. Eye protection?	Yes No
B. A face shield?	Yes No
C. A barrier gown, isolation gown, or disposable gown?	Yes No
D. Hearing protection?	Yes No
E. Latex or other type of disposable medical glove?	Yes No
F. Work gloves?	Yes No
G. A mask or respirator?	Yes No
H. A plastic apron?	Yes No
I. A self contained breathing apparatus (SCBA)?	Yes No

Assault and /or Violence Questions

(37) Did your [injury/illness/exposure] involve an animal attack, including an animal bite?

A. Yes

B. No

C. Don’t know

(38) Assaults or violent incidents may include hitting, spitting, verbal assaults, and threats, even if harm was not intended. Did your [injury/illness/exposure] involve an assault or violent incident by a person?

A. Yes

B. No (SKIP TO FALL OR LOSS OF BALANCE SECTION)

C. Don’t know (SKIP TO FALL OR LOSS OF BALANCE SECTION)

(39) What type of harm by a person did you experience? (Read categories.)

A. Verbal. This includes abusive language, threats of violence or injury, and gestures directed towards the provider.

B. Physical. This includes any unwanted physical contact directed toward the provider, including slapping, hitting, pushing, kicking or spitting.

C. Both verbal and physical.

D. Other, please describe: _______________________________________________

(40) Was the harm directed at you?

A. Yes

B. No

C. Don’t know

(41) Were police present at the time of the incident?

A. Yes

B. No

C. Don’t know

(42) Was a police report made because of the incident?

A. Yes

B. No

C. Don’t know

(43) Was a weapon involved in the incident?

A. Yes

B. No (SKIP TO Q45)

C. Don’t know (SKIP TO Q42)

(44) Please describe the weapon(s) used:____________________________________________

(45) Was there more than one person who inflicted harm on you?

A. Yes

B. No

C. Don’t know

(46) Please tell me yes or no if the following describes your assailant(s). (Read categories.)

A. A patient?	Yes No
B. A family member of a patient?	Yes No
C. A friend of a patient, including significant others?	Yes No
D. Someone else? Please describe: _____________________________________________________	Yes No
E. Don’t know	Yes No

IF NONE OF THE ASSAILANTS WERE PATIENTS, SKIP TO FALL OR LOSS OF BALANCE SECTION

(47) Did the patient appear to be under the influence of alcohol?

A. Yes

B. No

C. Don’t know

D. Not applicable

Fall or Loss of Balance Questions

(48) Did your [injury/illness/exposure] involve a fall, slip, trip, stumble, or any other loss of balance?

A. Yes

B. No (SKIP TO BODY MOTION SECTION)

C. Don’t know (SKIP TO BODY MOTION SECTION)

(49) Please tell me yes or no if the following were involved in your injury?

A. Going up or down stairs, steps, or a curb?	Yes No
B. Stepping into or out of a vehicle?	Yes No
C. Walking on a rough, uneven, or sloped surface such as an unlevel sidewalk or a steep bank?	Yes No
D. Turning a corner or negotiating a turn?	Yes No
E. Walking on a level surface?	Yes No

(50) Please tell me yes or no if any of the following hazards were involved in your injury?

A. Surface contamination such as liquid, grease, ice or snow?	Yes No
B. An object in the pathway of your movement?	Yes No

(51) Were you pushing, pulling, lifting, or carrying anything at the time of your injury?

A. Yes. Please describe:___________________________________________________

B. No

C. Don’t know

Body Motion Questions

(52) Did your [injury/illness/exposure] involve excessive physical effort, awkward body posture, or repetitive movement? (This section excludes falls.)

A. Yes

B. No (SKIP TO SUDDEN ILLNESS OR CARDIAC EVENT SECTION)

C. Don’t know (SKIP TO SUDDEN ILLNESS OR CARDIAC EVENT SECTION)

(53) Please tell me yes or no if the following were involved in your injury?

A. Going up or down stairs, steps, or a curb?	Yes No
B. Stepping into or out of a vehicle?	Yes No
C. Walking on a rough or uneven surface such as an unlevel sidewalk or a steep bank?	Yes No
D. Turning a corner or negotiating a turn?	Yes No
E. Twisting?	Yes No
F. Working above shoulder level?	Yes No

(54) Please tell me yes or no if any of the following hazards were involved in your injury?

A. Surface contamination such as liquid, grease, ice or snow?	Yes No
B. An object in the pathway of your movement?	Yes No

(55) Were you forced to use an awkward posture or movement because of the space you were working in?

A. Yes

B. No

C. Don’t know

(56)* Did this incident involve transferring, carrying, or lifting a patient or object?

A. Yes

B. No (SKIP TO Q55)

(57) Were you transferring, carrying, or lifting a person at the time of your injury?

A. Yes

B. No

C. Don’t know

(58) Were you transferring, carrying, or lifting equipment at the time of your injury?

A. Yes

B. No (SKIP TO Q61)

C. Don’t know (SKIP TO Q61)

(59) What equipment were you moving?

A. A backboard

B. A stretcher

C. A stair chair

D. Other, please describe: _______________________________________________

(60) How many other persons were assisting you with the transfer, carry, or lift? ____ ____

(61) Prior to this injury, did you have a sprain, strain, or repetitive motion injury to the same injured body part?

A. Yes

B. No

C. Don’t know

D. Not applicable, this injury/illness did not involve a sprain, strain, or repetitive motion injury

Sudden Illness or Cardiac Events (Given information from the respondent’s narrative descriptive, use the term “illness” or “cardiac event” wherever “illness/cardiac event” appears.)

(62) Did your [injury/illness/exposure] involve any sudden illness or cardiac event?

A. Yes

B. No (SKIP TO OCCUPATION AND EMPLOYMENT SECTION)

C. Don’t know (SKIP TO OCCUPATION AND EMPLOYMENT SECTION)

(63) What symptoms did you experience in relation to your [illness/cardiac event]? (Read categories. Select all that apply.)

A. Chest pain?	Yes No
B. Dizziness?	Yes No
C. Headache?	Yes No
D. Light-headedness or fainting?	Yes No
E. Nausea or vomiting?	Yes No
F. Numbness or tingling of one or more extremities?	Yes No
G. Shortness of breath?	Yes No
H. Other symptoms? Please describe: _________________________________________________	Yes No

(64) Had you experienced a similar [illness/cardiac event] in the past?

A. Yes, please describe:______________________________________________________

B. No

C. Don’t know

(65) Are you under treatment for any ongoing illness or cardiac problems?

A. Yes, please describe: _____________________________________________________

B. No

Occupation and Employment

Now, I’d like to ask you some specific questions about your job.

(66) At what level do you practice as an EMS worker? (Read categories.)

A. First responder

B. EMT-Basic

C. EMT-Intermediate, which is a level between EMT-B and paramedic

D. EMT-Paramedic

E. Other, please describe: ____________________________

(67) Have you been trained as a fire fighter?

A. Yes

B. No (IF NO, SKIP TO Q69)

(68) About how much of your work involves EMS duties? (Read categories. Select the most appropriate response.)

A. Almost none

B. Less than half

C. About half

D. More than half

E. All

(69) How many years have you worked, paid or volunteer, as an EMS provider? (Record months only if provided. If unknown, year = 99.)

1. Years = ___ Months = ___

2. Don’t know

(70) At the time of your [injury/illness/exposure], what kind of EMS worker were you functioning as? Were you: (Read categories.)

A. a full-time paid employee

B. a part-time paid employee

C. an on-call or as-needed paid employee,

D. a volunteer, or

E. something else?

Please describe:____________________________________________________

Equipment Use Questions

Now I have some questions about any equipment you may have been using when your [injury/illness/exposure] occurred. Even though you have already described the incident, I do not want to overlook any important details.

(71) What equipment were you using to complete the task you were working on at the time of your [injury/illness/exposure]? (Read categories. Select all that apply.)

A. An automated external defibrillator, also called an AED, or a cardiac monitor?	Yes No
B. A backboard?	Yes No
C. Manual or hand tools?	Yes No
D. A needle or syringe?	Yes No
E. An oxygen tank?	Yes No
F. A stair chair?	Yes No
G. A stretcher or cot?	Yes No
H. Vehicle extrication equipment?	Yes No
I. Other equipment? Please describe: ________________________________________________	Yes No
J. Don’t know	Yes No

Injury Outcome

I’m going to ask a couple of questions about follow-up care and any related [injury/illness/exposure] problems you may have experienced after your visit to the emergency department.

(72) When you were seen in the emergency department, did they recommend follow-up by another healthcare provider?

A. Yes

B. No (SKIP TO Q72)

C. Don’t know (SKIP TO Q72)

(73) Describe additional treatment you received after your ED visit, including the type of professional who performed the treatment and what type of treatment you received.

A. _______________________________________________________________________

____________________________________________________________________________________________________________________________________________

B. None

(74) After your injury, when did you go back to your EMS job? (Read categories.)

A. The same day your [injury/illness/exposure] occurred; (SKIP TO Q76)

B. The day following your [injury/illness/exposure] or your next scheduled workday; or (SKIP TO Q76)

C. You missed one or more days of work because of your [injury/illness/exposure]

D. You will not be returning to work (SKIP TO Q77)

E. Don’t know

(75) Not counting the day you [were injured/became ill/were exposed], how many days were you away from work due to your [injury/illness/exposure]?

A. ___ ___ ___

B. Continues to be off work

(IF 30 OR MORE DAYS, SKIP TO Q77)

(76) In the 30 days after your [injury/illness/exposure], were there any work duties you could not do because of your [injury/illness/exposure]?

A. Yes. Please describe:_____________________________________________________

__________________________________________________________________________________________________________________________________________________

B. No

(77) In the 30 days after your [injury/illness/exposure], were there any activities at home that you could not do because of your [injury/illness/exposure]?

A. Yes. Please describe:______________________________________________________

__________________________________________________________________________________________________________________________________________________

B. No

C. Was not able to return home within one month

(78) In the 30 days after your injury, did you experience any symptoms related to your [injury/illness/exposure]?

A. Yes. Please describe:______________________________________________________

__________________________________________________________________________________________________________________________________________________

B. No

(79) What is the long-term prognosis for recovery from your [injury/illness/exposure]? (Read categories.)

A. Full recovery (SKIP TO PHYSICAL CONDITION SECTION)

B. Permanent impairment

C. Don’t know (SKIP TO PHYSICAL CONDITION SECTION)

(80) Describe your permanent impairments:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physical condition

Now I am going to ask a few questions about yourself and your current health status.

(81) In what month and year were you born? ____ ____/____ ____ ____ ____

(82) In the month before your [injury/illness/exposure], how would you rate your overall health compared to other people your age? (Read categories.)

A. Excellent

B. Good

C. Fair

D. Poor

(82) In the month before your [injury/illness/exposure], how would you rate your overall physical fitness compared to other people your age? (Read categories.)

A. Excellent

B. Good

C. Fair

D. Poor

(83) During the past 12 months, have you had other EMS work-related injuries, illnesses, or exposures that required more medical treatment than first aid?

A. Yes

B. No

Thank you for your participation. We greatly appreciate your cooperation.

END INTERVIEW

*******************************

Questions for interviewer

(1) Did the respondent have difficulty completing this questionnaire? (Select all that apply.)

A. No

B. Difficulty hearing

C. Difficulty with language or language barrier

D. Difficulty understanding a question or response option. Please specify: _________________________________________________________________________

E. Other: _________________________________________________________________

(2) Did the interviewer have difficulty completing this questionnaire? (Select all that apply.)

A. Respondent was difficult to hear and/or understand

B. Respondent was not cooperative

C. Other: _________________________________________________________________

1

Public reporting burden of this collection of information is estimated to average 20 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0834).