Crib Falls guidelines

Crib Falls
Questionnaire # ________ (1-4)

Q.1 General Instructions:
Bold type indicates what should be said to the respondent. Instructions for the interviewer will
be prefaced by "Interviewer:" and are written in non-bold type face.
Q.2 Interviewer: Complete before dialing.
Please enter task number

[REQUIRE ANSWER]

____________________________________________________________________________

(5-17)

Q.3 Interviewer: Complete before dialing.
Enter hospital name

[REQUIRE ANSWER]

___________________________________________________________________________

(18-47)

Q.4 Interviewer: Complete before dialing.
Enter incident date in mmddyyyy format.

[REQUIRE ANSWER]
mmddyyyy ................. ________________ (48-55)

OMB Control Number 3041-0029

Q.5 Interviewer: Ask for parent / guardian of the patient, or an adult.
Introduction
Hello, may I speak with the parent or guardian of [patient's name] or an adult in the
household?
I am calling on behalf of the U.S. Consumer Product Safety Commission. We are trying
to learn more about cribs that have been involved in incidents where infants have fallen
or climbed out of them. This will help us in our effort to improve crib safety.
Your answers will be kept confidential. No names will be associated with the answers,
and the information collected will be used only for statistical purposes.
Are you familiar with the recent incident involving the fall / climb out of the crib which
resulted in a visit to the emergency room at [ANSWER TO Q. 3] on [ANSWER TO Q. 4]?
[REQUIRE ANSWER]
(56)

q1
q2
q3

Yes
No
No fall or crib involved

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 8]
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 7]

Q.6 Please give a brief summary of the reason for the emergency room visit.
Interviewer: After getting the response to this question, skip to Q37.
[REQUIRE ANSWER]
__________________________________________________________________________

(57-256)

[D - IF THE ANSWER TO QUESTION 5 IS 3, THEN SKIP TO QUESTION 37]

Q.7 Could I speak to another available adult who is familiar with the recent incident?
Interviewer: If the response is yes, ask to speak to that person.
[REQUIRE ANSWER]
(257)

q1
q2
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 37]

OMB Control Number 3041-0029

Yes
No

Q.8 What is your relationship with the patient?
[REQUIRE ANSWER]
(258)

q1
q2
q3

Parent
Guardian other than parent
Other

[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 10]

Q.9 Interviewer: Ask respondent to identify "Other" in Q8.
[REQUIRE ANSWER]
_________________________________________________________________________

(259-278)

Q.10 Do you have a few minutes to talk about the incident?
[REQUIRE ANSWER]
(279)

q1
q2

Yes
No

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 13]

Q.11 Can I call you back at a better time?
[REQUIRE ANSWER]
(280)

q1
q2

Yes
No

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 37]

Q.12 Please specify a better time.
Interviewer: After noting down the response, skip to Q37.
[REQUIRE ANSWER]
_________________________________________________________________________

(281-295)

[D - IF THE ANSWER TO QUESTION 11 IS 1, THEN SKIP TO QUESTION 37]

Q.13 Did you witness the incident?
[REQUIRE ANSWER]
(296)

q1
q2

OMB Control Number 3041-0029

Yes
No

Q.14 Please describe what happened.
[REQUIRE ANSWER]
________________________________________________________________________

(297-1296)

Q.15 What was the patient's height at the time of the incident?
[REQUIRE ANSWER]
_______________________________________________________________________

(1297-1326)

Q.16 Please describe the injury that the patient received.
[REQUIRE ANSWER]
_______________________________________________________________________

(1327-1526)

Q.17 What type of treatment was received at the emergency room?
[REQUIRE ANSWER]
_______________________________________________________________________

(1527-1626)

Q.18 If the patient stayed in the hospital overnight, how many nights did he/she stay there?
Interviewer: If the child did NOT stay overnight, enter 00; if child stayed overnight but the
number of nights is unknown, then enter 99.
[REQUIRE ANSWER]
...... ____ (1627-1628)

Q.19 Now I would like ask some questions about the crib.
Does the crib have a moveable drop side?
[REQUIRE ANSWER]
(1629)

q1
q2
q3
[S - IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 21]

OMB Control Number 3041-0029

Yes
No
Unknown

Q.20 What was the position of the drop side at the time of the incident: up, down, or
unknown?
[REQUIRE ANSWER]
(1630)

q1
q2
q3

Up
Down
Unknown

Q.21 What was the mattress setting at the time of the incident: highest, middle, lowest, or
unknown?
Interviewer: If there are multiple settings between the highest and the lowest, consider them all
as "middle" setting.
[REQUIRE ANSWER]
(1631)

q1
q2
q3
q4

Highest
Middle
Lowest
Unknown

Q.22 What is the crib's manufacturer name (make)?
Interviewer: Allow respondent to step away to look it up if necessary.
[REQUIRE ANSWER]
_______________________________________________________________________

(1632-1661)

Q.23 What is the crib's model name / number?
Interviewer: Allow respondent to step away to look it up if necessary.
[REQUIRE ANSWER]
_______________________________________________________________________

(1662-1681)

Q.24 What is the approximate age of the crib?
[REQUIRE ANSWER]
_______________________________________________________________________

OMB Control Number 3041-0029

(1682-1701)

Q.25 What was the condition of the crib when first obtained: new, used, or unknown?
(1702)

q1
q2
q3

New
Used
Unknown

Q.26 Where was the crib obtained from?
Interviewer: This could be a retailer (obtain specific name if known), relative/friend, yard sale,
etc. or unknown.
_______________________________________________________________________

(1703-1722)

Q.27 Now I would like to ask you about the patient's developmental history such as when
he/she first pulled up to a stand, when first walked, etc. Would you be able to answer?
[REQUIRE ANSWER]
(1723)

q1
q2

Yes
No

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 31]

Q.28 Is there another adult I can speak to who would be able to answer?
Interviewer: If the response is yes, ask to speak to that person.
[REQUIRE ANSWER]
(1724)

q1
q2

Yes
No

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 36]

Q.29 What is your relationship with the victim?
[REQUIRE ANSWER]
(1725)

q1
q2
q3

Parent
Guardian other than parent
Other

[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 31]

Q.30 Interviewer: Ask respondent to specify "Other" in Q29.
[REQUIRE ANSWER]
_______________________________________________________________________

OMB Control Number 3041-0029

(1726-1745)

Q.31 At what age did the patient first pull up to a stand?
[REQUIRE ANSWER]
_______________________________________________________________________

(1746-1775)

Q.32 At what age did the patient first walk without support?
[REQUIRE ANSWER]
_______________________________________________________________________

(1776-1805)

Q.33 Has the patient fallen out of this crib before?
[REQUIRE ANSWER]
(1806)

q1
q2
q3

Yes
No
Unknown

[S - IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 36]

Q.34 What was the patient's approximate height at the time of that incident?
[REQUIRE ANSWER]
_______________________________________________________________________

(1807-1836)

Q.35 What was the patient's age then?
[REQUIRE ANSWER]
_______________________________________________________________________

(1837-1866)

Q.36 This concludes the survey. I thank you very much for your cooperation and your time
in our effort to improve crib safety.
If I missed anything, may I call you back?
[REQUIRE ANSWER]
(1867)

q1
q2

Yes
No

[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 38]

Q.37 Thank you for your time.

Q.38 Interviewer: Enter the date this interview was completed in mmddyyyy format.
mmddyyyy .................. ________________ (1868-1875)

OMB Control Number 3041-0029