General Respondent NEISS

General Questionnaire
Questionnaire # ________

Q.1 Interviewer Instructions:
Please do not read 'DON'T KNOW' and 'REFUSED' response choices aloud.
Purpose:
1) Confirm injury/ER visit data contained in NEISS
2) Gather information on race/ethnicity, cell phone, and internet usage to help us focus
consumer education and outreach, inform survey design decisions, and improve survey
response rates. Additional questions probe respondents' willingness to complete surveys if
offered a monetary incentive.
For questions, please contact
Michelle Finch, 301-504-7505, [email protected] or
Mary Cowhig, 301-504-7418, [email protected]
CPSC EPDS

Q.2 Interviewer: Complete before dialing. Please enter task number.
_______________________________________________
_______________________________________________________________________________________

Q.3 Hello, may I speak with __________?
I'm calling on behalf of the U.S. Consumer Product Safety Commission. We analyze hospital emergency
room data on injuries involving consumer products. We would like to ask you some questions that will
help us improve our reporting capabilities and our ability to reach consumers with important product
safety information.
Your answers will be kept confidential; no names will be associated with the answers. The information
you provide will be used for statistical purposes only. You may, at any time, end the survey before
completion. May I have a few minutes of your time?
Yes
No

1
2

Yes
No

1
2

[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 6]

Q.4 Is there a better time when I may call you back?

[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 5]
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 32]

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Q.5 Please indicate the more convenient time.
_______________________________________________________________________________________
_______________________________________________________________________________________
[IF THE ANSWER TO QUESTION 4 IS 1, THEN SKIP TO QUESTION 32]

Q.6 I understand that you visited the _______________ Emergency Room for an injury involving a/an
_____________________. Can you briefly describe what happened?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.7 Due to the cultural diversity in the United States, we sometimes have difficulty communicating
important product safety information to consumers. The following race and ethnicity questions
will help us better focus our outreach and education efforts related to consumer product safety.

Q.8 Do you consider yourself to be Hispanic or Latino?
Yes
No
Don't know
Refused

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2
3
4

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Q.9 Interviewer: Please read race choices aloud and ask respondent to select ALL categories that
apply. If respondent replies with anything other than the first 5 categories, select "Other" and
in next question, enter their answer verbatim.
What race or races do you consider yourself to be?
White
Black/African American
Native American/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
Other
Don't know
Refused

1
2
3
4
5
6
7
8

[IF THE ANSWER IS NOT 6, THEN SKIP TO QUESTION 11]

Q.10 Please specify "other" race.
Interviewer: if respondent states 'biracial' or 'multiracial', please prompt for specifics (country
of origin, nationality, etc.) Otherwise, simply state 'biracial' or 'multiracial'.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.11 Like many other federal government agencies, the CPSC has difficulty reaching people and
getting them to respond to surveys. The next few questions deal with your cell phone and
internet usage and your preference for one survey method over another.

Q.12 Did I reach you on a cell phone for this call?
Yes

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1

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No
Don't know
Refused

2
3
4

Yes
No
Don't know
Refused

1
2
3
4

[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 14]

Q.13 Do you or anyone in your family have a working cell phone?

[IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 19]

Q.14 How many working cell phones do you or people in your family have?
__
[IF THE ANSWER TO QUESTION 12 IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 18]

Q.15 Is there at least one telephone inside your home that is currently working that is NOT a cell phone?
Yes
No
Don't know

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2
3

-4-

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Refused

4

Q.16 Please select the following response that best describes your current location:
At home
At work
Inside a motor vehicle
Other
Don't know
Refused

1
2
3
4
5
6

[IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 18]

Q.17 Please specify "other" location
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.18 Please select the answer that best describes your cell phone usage:
All or most all calls received on cell phones
Some received on cell phones and some on regular phones
Very few or no calls on cell phones
Don't know
Refused

1
2
3
4
5

Q.19 Do you have caller id on this phone?
Yes
No
Don't know
Refused

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Q.20 Would you answer a call from an unknown or blocked number?
Yes
No
Don't know
Refused

1
2
3
4

Q.21 Please select one of the following that best describes how frequently you use the internet:
Daily
Weekly
Monthly
At least once per year
Do not use internet
Don't know
Refused

1
2
3
4
5
6
7

[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 26]

Q.22 Typically which of the following equipment do you use most often to access the internet?
Computer
Cell phone
Other portable device
Don't know
Refused
[IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 24]

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2
3
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5

Q.23 Please specify "other" portable device.
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.24 Where do you access the internet most often for personal use?
Home
Work
Public library
Internet cafe
Other public place
Don't know
Refused

1
2
3
4
5
6
7

[IF THE ANSWER IS NOT 5, THEN SKIP TO QUESTION 26]

Q.25 Please specify "other public place."
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.26 Which method would you prefer for answering a survey:
Telephone
Internet
Mail
No preference
Refused
[IF THE ANSWER IS NOT 2, THEN SKIP TO QUESTION 28]

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2
3
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Q.27 If a monetary incentive were provided upon completion of a survey, would you be more likely to answer
the survey?
Yes
No
Don't know
Refused

1
2
3
4

[IF THE ANSWER TO QUESTION 26 IS 2, AND...]
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 30]
[IF THE ANSWER IS NOT 2, THEN SKIP TO QUESTION 29]

Q.28 If a monetary incentive were provided, would you complete an INTERNET based survey?
Yes
No
Don't know
Refused

1
2
3
4

[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 30]

Q.29 For future surveys, which of the following would be the minimal amount you would consider appropriate
compensation for completing a survey?
$10
$20
$30
$40
$50

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2
3
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5

Q.30 Do you have any comments or suggestions that might help us improve survey completions?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Q.31 On behalf of the U.S. Consumer Product Safety Commission, I would like to thank you for your
time and cooperation with this interview.

Q.32 Thank you for your time.
Interviewer: End interview.

Q.33 Interviewer: Please enter date interview was completed (MMDDYY)?
MMDDYY

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