Generators guidelines

NEISS Generator Questionaire
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 is written in a non-bold type face.

Q.2

INTERVIEWER: Please enter the Task Number
[REQUIRE ANSWER]
_________________________________________________________________________________

Q.3

(5-17)

INTERVIEWER: Enter name of hospital the victim was treated at:
[REQUIRE ANSWER]
________________________________________________________________________________

Q.4

(18-67)

INTERVIEWER: If the injured person is under 18 years of age, ask for the parent or guardian.
Introduction:
Hello, may I speak with ____________________ ?
I am calling for the U.S. Consumer Product Safety Commission. I understand that you or
someone in your household recently received an injury caused by a generator. We are
presently performing a study on generator-related injuries and would like to ask you some
questions about the incident.
INTERVIEWER: Be prepared to answer questions with the following information:
- that the identity of the involved individuals will be kept confidential
- that the purpose of the study is to prevent future incidents and injuries associated with the use of
generators
[REQUIRE ANSWER]
(68)

q 1 Agree to participate
q 2 Decline to participate
q 3 No generator was involved
[A - IF THE ANSWER TO QUESTION 4 IS 2, THEN SKIP TO QUESTION 369]
[A - IF THE ANSWER TO QUESTION 4 IS 3, THEN SKIP TO QUESTION 12]
OMB Control Number 3041-0029

Q.5

Are you familiar with the details of the incident?

[REQUIRE ANSWER]
(69)

q 1 Yes
q 2 No
[A - IF THE ANSWER TO QUESTION 5 IS 1, THEN SKIP TO QUESTION 10]

Q.6

Do you know of someone else who is more familiar with the details of the incident?
[REQUIRE ANSWER]
(70)

q 1 Yes
q 2 No
[A - IF THE ANSWER TO QUESTION 6 IS 2, THEN SKIP TO QUESTION 369]

Q.7

Could you tell me their name and phone number if different from this one.
INTERVIEWER: Record name and phone number (if different).
[REQUIRE ANSWER]
_______________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 6 IS 2, THEN SKIP TO QUESTION 369]

Q.8

May I speak with him/her?
[REQUIRE ANSWER]
(101)

q 1 Yes
q 2 No
[A - IF THE ANSWER TO QUESTION 8 IS 1, THEN SKIP TO QUESTION 10]

OMB Control Number 3041-0029

(71-100)

Q.9

When would be a good time to contact him/her?
[REQUIRE ANSWER]
______________________________________________________________________________

(102-131)

[A - IF THE ANSWER TO QUESTION 8 IS 2, THEN SKIP TO QUESTION 369]

Q.10

INTERVIEWER: Who is the respondent?
[REQUIRE ANSWER]
(132)

q 1 Injured person
q 2 Parent or guardian of the injured person
q 3 Other (specify in next window)
[A - IF THE ANSWER TO QUESTION 10 IS NOT 3, THEN SKIP TO QUESTION 12]

Q.11

INTERVIEWER: Identify "other" person.
[REQUIRE ANSWER]
______________________________________________________________________________

OMB Control Number 3041-0029

(133-172)

Q.12

Could you describe the incident?
[REQUIRE ANSWER]
______________________________________________________________________________

(173-572)

[A - IF THE ANSWER TO QUESTION 4 IS 3, THEN SKIP TO QUESTION 369]

Q.13

Was the injury involving the generator carbon monoxide poisoning, an electrical shock, a burn,
or another type of injury?
[REQUIRE ANSWER]
(573)

q1
q2
q3
q4
q5

Carbon monoxide poisoning
Electrical shock
Burn
Other (specify next window)
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 13 IS 1, THEN SKIP TO QUESTION 15]
[A - IF THE ANSWER TO QUESTION 13 IS 3, THEN SKIP TO QUESTION 16]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 4, THEN SKIP TO QUESTION 16]

Q.14

INTERVIEWER: Describe "other" injury.
[REQUIRE ANSWER]
______________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 17]

Q.15

Was this carbon monoxide poisoning incident related to a fire?
[REQUIRE ANSWER]
(624)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 17]

OMB Control Number 3041-0029

(574-623)

Q.16

Was this a burn from contacting the generator or its exhaust, or from a fire involving the
generator?
[REQUIRE ANSWER]
(625)

q 1 Contacting the generator or its exhaust
q 2 Fire involving the generator
q 3 Don't know / Refuse
Q.17

Could you please tell me what happened just before, during and after the incident?
[REQUIRE ANSWER]
_____________________________________________________________________________

Q.18

(626-1125)

How many victims total were injured and/or treated in this incident including yourself / the
victim? Please only include members of your household or people visiting with you.

INTERVIEWER: The maximum allowable number of victims for THIS survey is five (5). BUT, please enter
the number that the respondent answered. The respondent will be asked about only five victims at this
time. A follow-up call may be made for an incident that involved more then five injuries.
Enter "99" for "don't know" or refusal.
[REQUIRE ANSWER]
____ (1126-1127)

Q.19

Were there any fatalities associated with this incident?
INTERVIEWER: If "No" enter "0" (zero), otherwise enter the number of fatalities. Enter "99" for "don't
know" or refuse.
[REQUIRE ANSWER]
____ (1128-1129)
[A - IF THE ANSWER TO QUESTION 18 IS 1, THEN SKIP TO QUESTION 22]

OMB Control Number 3041-0029

Q.20

Did all of the surviving victims go to the same hospital?
[REQUIRE ANSWER]
(1130)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 20 IS NOT 2, THEN SKIP TO QUESTION 22]

Q.21

What hospitals did the other victims go to?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.22

(1131-1230)

What was the reason for using the generator?
INTERVIEWER: Please select response from the list below thatbest
" " characterizes the answer given. If
"other", please fill in any details in the following screen.
[REQUIRE ANSWER]
(1231)

q1
q2
q3
q4
q5
q6
q7

Weather related power outage (ice / snow)
Weather related power outage (rain / wind / other)
Power needed for construction or renovation
Power needed in a location without electricity, for example a shed or garage
Power not yet turned on by power company at new residence
Power turned off by power company due to billing dispute or other reason
Other
[A - IF THE ANSWER TO QUESTION 22 IS NOT 7, THEN SKIP TO QUESTION 24]

OMB Control Number 3041-0029

Q.23

INTERVIEWER: Enter details about the reason for using the generator:
[REQUIRE ANSWER]
____________________________________________________________________________

Q.24

(1232-1431)

Where was the generator located at the time of the incident?
INTERVIEWER: Please select the choice that best fits the situation. If different from items 1 through 17
choose "18 - none of the above" and asks for specifics (on the next page).
[REQUIRE ANSWER]
(1432-1433)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18
q 19

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
outside (not inside any structure)
none of the above / other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 24 IS NOT 18, THEN SKIP TO QUESTION 26]

OMB Control Number 3041-0029

Q.25

Could you describe the location of the generator at the time of the incident?
[REQUIRE ANSWER]
____________________________________________________________________________

(1434-1583)

[A - IF THE ANSWER TO QUESTION 24 IS 19, THEN SKIP TO QUESTION 27]

Q.26

Was there any reason that the generator was located where it was?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.27

(1584-1783)

What was the generator being used to power?
[REQUIRE ANSWER]
____________________________________________________________________________

(1784-1983)

[A - IF THE ANSWER TO QUESTION 18 IS 1 OR 99, THEN SKIP TO QUESTION 30]

Q.28

INTERVIEWER, say: "The next questions deal with information about the [ANSWER TO Q. 18]
victims of the generator incident. I want to remind you that this information will be used for
statistical purposes only. I will not ask you the names of the individuals, and your answers will
be kept completely confidential."

Q.29

The following information is about the first victim who we will refer to as “Victim A”.
INTERVIEWER: This should be the victim whose name appears on the NEISS report. Identify them by
name to the respondent.

[A - IF THE ANSWER TO QUESTION 18 IS NOT 1 OR 99, THEN SKIP TO QUESTION 32]

OMB Control Number 3041-0029

Q.30

INTERVIEWER, say: "The next questions deal with information about the victim of the generator
incident. I want to remind you that this information will be used for statistical purposes only. I
will not ask you the names of the individuals, and your answers will be kept completely
confidential."

Q.31

The following information is about the victim who we will refer to as “Victim A”.
INTERVIEWER: This should be the victim whose name appears on the NEISS report. Identify them by
name to the respondent.

Q.32

What was Victim A’s age at the time of the incident?
INTERVIEWER: Enter age in years if two years old or older. For a child under two years of age, enter 2
digit months preceded by "2". For example, 3 months old would be "203"; 18 months old would be "218".
Enter "999" for "Don't know / Refuse".
[REQUIRE ANSWER]
______ (1984-1986)

Q.33

Is Victim A male or female?
[REQUIRE ANSWER]
(1987)

q 1 Male
q 2 Female
q 3 Don't Know / Refuse
Q.34

What is your relationship to Victim A?
INTERVIEWER: Enter "Self" if the respondent is "Victim A".
[REQUIRE ANSWER]
____________________________________________________________________________

Q.35

(1988-2007)

Did the injury to Victim A occur while the victim was outside or within some type of structure?
[REQUIRE ANSWER]
(2008)

OMB Control Number 3041-0029

q 1 Outside
q 2 Inside
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 35 IS NOT 2, THEN SKIP TO QUESTION 48]

Q.36

I would like to read you a list, would you select the one that best describes the structure where
victim was located:
INTERVIEWER: Please read list through #16
[REQUIRE ANSWER]
(2009-2010)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
none of the above
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 36 IS NOT 17, THEN SKIP TO QUESTION 38]

Q.37

Can you describe the location of the victim at time of the injury?
[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 68]

OMB Control Number 3041-0029

(2011-2160)

Q.38

INTERVIEWER: The next set of questions is for victims of CARBON MONOXIDE injuries.
Where was Victim A located in the structure at the time of the incident? Please specify what
floor level and room that the victim was located in if known.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.39

(2161-2260)

Can you tell me about how long was the victim exposed to the CO?
INTERVIEWER: Please express this time in hours or fractional hours. For example, 90 minutes = 1.5
hours; 15 minutes = 0.25 hours. Please enter "99" if the respondent states that they do not know or
refuse to answer.
[REQUIRE ANSWER]
________________ (2261-2268)

Q.40

At Victim A's location at the time of the incident, were one or more windows open?
[REQUIRE ANSWER]
(2269)

q1
q2
q3
q4

Yes
No
Structure has no windows
Don't Know
[A - IF THE ANSWER TO QUESTION 40 IS NOT 1, THEN SKIP TO QUESTION 44]

Q.41

How many windows?
INTERVIEWER: Enter "99" for "Do not know" or refusal.
[REQUIRE ANSWER]
____ (2270-2271)
[A - IF THE ANSWER TO QUESTION 41 IS NOT 1, THEN SKIP TO QUESTION 43]

OMB Control Number 3041-0029

Q.42

From the following list, how open would you say the window at the victim's location was at the
time of the incident?
INTERVIEWER: please read list to respondent.

[REQUIRE ANSWER]
(2272)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 41 IS 1 OR 99, THEN SKIP TO QUESTION 44]

Q.43

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
[REQUIRE ANSWER]
(2273)

q1
q2
q3
q4
q5
q6
q7
Q.44

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at Victim A’s location?
[REQUIRE ANSWER]
(2274)

q1
q2
q3
q4

Yes
No
Structure has no door
Don't Know
[A - IF THE ANSWER TO QUESTION 44 IS NOT 1, THEN SKIP TO QUESTION 46]

OMB Control Number 3041-0029

Q.45

How open would you say the door was?
[REQUIRE ANSWER]
(2275)

q1
q2
q3
q4
Q.46

wide open
partially open
open just a crack
Don't Know / Refuse

Was there any other type of ventilation at Victim A's location such as a fan running or an air
conditioner?
[REQUIRE ANSWER]
(2276)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 46 IS NOT 1, THEN SKIP TO QUESTION 48]

Q.47

What other type of ventilation was used at Victim A's location?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.48

(2277-2376)

Can you tell me about the general health status of Victim A at time of incident? Please identify
any drugs/medications/alcohol being taken at the time of incident.
[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 54]

Q.49

Is Victim A currently a smoker?
[REQUIRE ANSWER]
(2577)

q 1 Yes

OMB Control Number 3041-0029

(2377-2576)

q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 49 IS NOT 1, THEN SKIP TO QUESTION 52]

Q.50

What type of product does Victim A primarily smoke - Cigarettes, Cigars or Pipes?
[REQUIRE ANSWER]
(2578)

q1
q2
q3
q4

Cigarettes
Cigars
Pipes
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 50 IS 4, THEN SKIP TO QUESTION 52]

Q.51

How many [ANSWER TO Q. 50] would you say Victim A smoke per day?
INTERVIEWER: Enter "99" for "Do not know" or refusal to answer.
[REQUIRE ANSWER]
____ (2579-2580)

Q.52

Returning to the carbon monoxide exposure, could you please describe Victim A’s symptoms?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(2581-2780)

Q.53

[ANSWER TO Q. 52]
INTERVIEWER: Check all that apply from description above – for those not checked ask respondent if
they know if Victim A experienced any of the other specific symptoms:
INTERVIEWER: Hit E
" nter" after each choice. Hit "Enter" again of click "Next" to move on to the next
question. Please note that unselected choices are inBOLD, selected choices are innon-BOLD.
[REQUIRE ANSWER]
(2781-2798)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
Q.54

None
Headache
Fatigue
Sleepy
Disorientation
Nausea
Vomiting
Chest Pains
Shortness of Breath
Loss of Consciousness
Don't know / Refuse

Were emergency personnel called to the scene or did the victim arrive at the Emergency Room by
personal vehicle?
[REQUIRE ANSWER]
(2799)

q 1 Emergency Responders arrived at the scene
q 2 By personal vehicle
q 3 Other / Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 54 IS NOT 1, THEN SKIP TO QUESTION 60]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 56]

Q.55

Do you know if the emergency responders took CO measurements at the scene? If so, do you
know what the readings were? These are usually expressed in parts per million (ppm).
INTERVIEWER: Enter numeric value if the respondent knows the measurement. Enter "9999" if they
don't know or refuse to answer the question.
[REQUIRE ANSWER]
________ (2800-2803)

OMB Control Number 3041-0029

Q.56

Did Victim A receive treatment at the scene?
[REQUIRE ANSWER]
(2804)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 56 IS NOT 1, THEN SKIP TO QUESTION 58]

Q.57

Please describe the treatment Victim A received at the scene and who treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.58

Was treatment received en route to Emergency Room?
[REQUIRE ANSWER]
(3005)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 58 IS NOT 1, THEN SKIP TO QUESTION 60]

OMB Control Number 3041-0029

(2805-3004)

Q.59

Please describe the treatment Victim A received en route to the Emergency Room and who
treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.60

(3006-3205)

Was treatment received at Emergency Room?
[REQUIRE ANSWER]
(3206)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 60 IS NOT 1, THEN SKIP TO QUESTION 64]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 66]

Q.61

Was oxygen given by face mask to Victim A? This may have been referred to as "100%
normobaric oxygen" or "NBO".
[REQUIRE ANSWER]
(3207)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 61 IS NOT 1, THEN SKIP TO QUESTION 63]

Q.62

How long was the victim given oxygen?
INTERVIEWER: Please enter as hours and/or fractions of hours. Enter 99 for don't know/refused.

[REQUIRE ANSWER]
__________ (3208-3212)

Q.63

Did Victim A receive treatment in a hyperbaric chamber? This may have been referred to as
"hyperbaric oxygen" or "HBO".
[REQUIRE ANSWER]
(3213)

OMB Control Number 3041-0029

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
Q.64

Was a blood CO level, or carboxyhemoglobin (COHb) level, taken for Victim A?
[REQUIRE ANSWER]
(3214)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 64 IS NOT 1, THEN SKIP TO QUESTION 66]

Q.65

What was the level? This number is usually expressed as a percentage.
INTERVIEWER: Please enter "999" if they respondent doesn't know or refuses to answer. Do not
include the percent sign (%).
[REQUIRE ANSWER]
______ (3215-3217)

Q.66

Was any further treatment recommended by the hospital staff or sought by the victim after they
were discharged?
[REQUIRE ANSWER]
(3218)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 66 IS NOT 1, THEN SKIP TO QUESTION 84]

OMB Control Number 3041-0029

Q.67

What treatment was recommended?
[REQUIRE ANSWER]
____________________________________________________________________________

(3219-3418)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 76]

Q.68

INTERVIEWER: The next set of questions is for victims of FIRE or CONTACT BURN-related injuries.
What was the Victim A doing when the burn was sustained?

[REQUIRE ANSWER]
(3419)

q1
q2
q3
q4

Refilling tank
Passing by generator
Other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 68 IS NOT 3, THEN SKIP TO QUESTION 70]

Q.69

Can you describe what the victim was doing?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.70

(3420-3569)

For Victim A, what body part was burned?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(3570-3719)

Q.71

How large was the overall burn area?
INTERVIEWER: Please enter answer as either % of skin surface / L x W in inches; Enter "Do not known"
if unknown or refusal.

[REQUIRE ANSWER]
____________________________________________________________________________

Q.72

(3720-3769)

What was the most severe level of burn: 1st Degree burn (reddening), 2nd Degree burn
(blistering) or 3rd Degree burn (full skin thickness burn)?
[REQUIRE ANSWER]
(3770)

q1
q2
q3
q4

1st Degree Burn
2nd Degree Burn
3rd Degree Burn
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 72 IS 4, THEN SKIP TO QUESTION 74]

Q.73

About what fraction of the total burn area was a [ANSWER TO Q. 72] - One quarter, One half,
Three Quarters, or Whole burn area?
[REQUIRE ANSWER]
(3771)

q1
q2
q3
q4
q5
Q.74

1/4 of burn area
1/2 of burn area
3/4 of burn area
whole burn area
Don't Know / Refuse

Which of the following best describes how Victim A medically treated?
INTERVIEWER: Please read to respondent and check one.

[REQUIRE ANSWER]
(3772)

q 1 treated and released
q 2 admitted to hospital
q 3 transferred to burn unit

OMB Control Number 3041-0029

q 4 Don't Know / Refuse
Q.75

How was the burn treated? (e.g. bandages and topical antibiotics; skin graft; etc.)
[REQUIRE ANSWER]
____________________________________________________________________________

(3773-3872)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 2, THEN SKIP TO QUESTION 84]

Q.76

INTERVIEWER: The next set of questions is for victims of ELECTRICAL SHOCK injuries.
Where did the electricity enter and exit Victim A's body (what body part)?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.77

What did Victim A touch or contact when he/she was shocked?
INTERVIEWER: please check one

[REQUIRE ANSWER]
(4023)

q1
q2
q3
q4
q5

The generator itself
Extension cord connected to the generator
Appliance being powered by generator
Other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 77 IS NOT 4, THEN SKIP TO QUESTION 79]

OMB Control Number 3041-0029

(3873-4022)

Q.78

Could you please describe the contact source in detail?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.79

(4024-4173)

Please describe the situation when the electric shock took place. For example, was the victim
standing in puddle; plugging in an appliance; did the victim have shoes on; etc.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.80

(4174-4373)

What were the weather conditions?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.81

(4374-4473)

Can you describe Victim A's injury severity?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.82

(4474-4673)

Who rescued the victim?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(4674-4723)

Q.83

What medical treatment was given to Victim A?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.84

(4724-4873)

How long was the victim in the hospital?
INTERVIEWER: Enter answer in DAYS. If "treated and released" the same day enter "0". If unknown or
refusal to answer enter "999".
[REQUIRE ANSWER]
______ (4874-4876)

Q.85

What is the current status and prognosis for Victim A?

[REQUIRE ANSWER]
____________________________________________________________________________

(4877-5076)

[A - IF THE ANSWER TO QUESTION 18 IS 1 OR 99, THEN SKIP TO QUESTION 298]

Q.86

The following information is about the second victim who we will refer to as “Victim B”. This
can be any one of the victims, I would just ask you to keep this person in mind when answering
the following questions.

Q.87

What was Victim B’s age at the time of the incident?
INTERVIEWER: Enter age in years if two years old or older. For a child under two years of age, enter 2
digit months preceded by "2". For example, 3 months old would be "203"; 18 months old would be "218".
Enter "999" for "Don't know / Refuse".
[REQUIRE ANSWER]
______ (5077-5079)

OMB Control Number 3041-0029

Q.88

Is Victim B male or female?
[REQUIRE ANSWER]
(5080)

q 1 Male
q 2 Female
q 3 Don't Know / Refuse
Q.89

What is your relationship to Victim B?
INTERVIEWER: Enter "Self" if the respondent is "Victim B".
[REQUIRE ANSWER]
____________________________________________________________________________

Q.90

(5081-5100)

Did the injury to Victim B occur while the victim was outside or within some type of structure?
[REQUIRE ANSWER]
(5101)

q 1 Outside
q 2 Inside
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 90 IS NOT 2, THEN SKIP TO QUESTION 103]

OMB Control Number 3041-0029

Q.91

I would like to read you a list, would you select the one that best describes the structure where
victim was located:
INTERVIEWER: Please read list through #16
[REQUIRE ANSWER]
(5102-5103)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
none of the above
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 91 IS NOT 17, THEN SKIP TO QUESTION 93]

Q.92

Can you describe the location of the victim at time of the injury?
[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 121]

OMB Control Number 3041-0029

(5104-5253)

Q.93

INTERVIEWER: The next set of questions is for victims of CARBON MONOXIDE injuries.
Where was Victim B located in the structure at the time of the incident? Please specify what
floor level and room that the victim was located in if known.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.94

(5254-5353)

Can you tell me about how long was the victim exposed to the CO?
INTERVIEWER: Please express this time in hours or fractional hours. For example, 90 minutes = 1.5
hours; 15 minutes = 0.25 hours. Please enter "99" if the respondent states that they do not know or
refuse to answer.
[REQUIRE ANSWER]
________________ (5354-5361)

Q.95

At Victim B's location at the time of the incident, were one or more windows open?
[REQUIRE ANSWER]
(5362)

q1
q2
q3
q4

Yes
No
Structure has no windows
Don't Know
[A - IF THE ANSWER TO QUESTION 95 IS NOT 1, THEN SKIP TO QUESTION 99]

Q.96

How many windows?
INTERVIEWER: Enter "99" for "Do not know" or refusal.
[REQUIRE ANSWER]
____ (5363-5364)
[A - IF THE ANSWER TO QUESTION 96 IS NOT 1, THEN SKIP TO QUESTION 98]

OMB Control Number 3041-0029

Q.97

From the following list, how open would you say the window at the victim's location was at the
time of the incident?
INTERVIEWER: please read list to respondent.

[REQUIRE ANSWER]
(5365)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 96 IS 1 OR 99, THEN SKIP TO QUESTION 99]

Q.98

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
[REQUIRE ANSWER]
(5366)

q1
q2
q3
q4
q5
q6
q7
Q.99

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at Victim B’s location?
[REQUIRE ANSWER]
(5367)

q1
q2
q3
q4

Yes
No
Structure has no door
Don't Know
[A - IF THE ANSWER TO QUESTION 99 IS NOT 1, THEN SKIP TO QUESTION 101]

OMB Control Number 3041-0029

Q.100

How open would you say the door was?
[REQUIRE ANSWER]
(5368)

q1
q2
q3
q4
Q.101

wide open
partially open
open just a crack
Don't Know / Refuse

Was there any other type of ventilation at Victim B's location such as a fan running or an air
conditioner?
[REQUIRE ANSWER]
(5369)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 101 IS NOT 1, THEN SKIP TO QUESTION 103]

Q.102

What other type of ventilation was used at Victim B's location?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.103

(5370-5469)

Can you tell me about the general health status of Victim B at time of incident? Please identify
any drugs/medications/alcohol being taken at the time of incident.

[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 109]

Q.104

Is Victim B currently a smoker?
[REQUIRE ANSWER]
(5670)

OMB Control Number 3041-0029

(5470-5669)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 104 IS NOT 1, THEN SKIP TO QUESTION 107]

Q.105

What type of product does Victim B primarily smoke - Cigarettes, Cigars or Pipes?
[REQUIRE ANSWER]
(5671)

q1
q2
q3
q4

Cigarettes
Cigars
Pipes
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 105 IS 4, THEN SKIP TO QUESTION 107]

Q.106

How many [ANSWER TO Q. 105] would you say Victim B smoke per day?
INTERVIEWER: Enter "99" for "Do not know" or refusal to answer.
[REQUIRE ANSWER]
____ (5672-5673)

Q.107

Returning to the carbon monoxide exposure, could you please describe Victim B’s
symptoms?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(5674-5873)

Q.108

[ANSWER TO Q. 107]
INTERVIEWER: Check all that apply from description above – for those not checked ask respondent if
they know if Victim B experienced any of the other specific symptoms:
INTERVIEWER: Hit E
" nter" after each choice. Hit "Enter" again of click "Next" to move on to the next
question. Please note that unselected choices are inBOLD, selected choices are innon-BOLD.
[REQUIRE ANSWER]
(5874-5891)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
Q.109

None
Headache
Fatigue
Sleepy
Disorientation
Nausea
Vomiting
Chest Pains
Shortness of Breath
Loss of Consciousness
Don't know / Refuse

Did Victim B receive treatment at the scene?
[REQUIRE ANSWER]
(5892)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 109 IS NOT 1, THEN SKIP TO QUESTION 111]

OMB Control Number 3041-0029

Q.110

Please describe the treatment Victim B received at the scene and who treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.111

(5893-6092)

Was treatment received en route to Emergency Room?
[REQUIRE ANSWER]
(6093)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 111 IS NOT 1, THEN SKIP TO QUESTION 113]

Q.112

Please describe the treatment Victim B received en route to the Emergency Room and who
treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.113

(6094-6293)

Was treatment received at Emergency Room?
[REQUIRE ANSWER]
(6294)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 113 IS NOT 1, THEN SKIP TO QUESTION 117]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 119]

Q.114

Was oxygen given by face mask to Victim B? This may have been referred to as "100%
normobaric oxygen" or "NBO".
[REQUIRE ANSWER]
(6295)

q 1 Yes

OMB Control Number 3041-0029

q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 114 IS NOT 1, THEN SKIP TO QUESTION 116]

Q.115

How long was the victim given oxygen?
INTERVIEWER: Please enter as hours and/or fractions of hours.

[REQUIRE ANSWER]
__________ (6296-6300)

Q.116

Did Victim B receive treatment in a hyperbaric chamber? This may have been referred to as
"hyperbaric oxygen" or "HBO".
[REQUIRE ANSWER]
(6301)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
Q.117

Was a blood CO level, or carboxyhemoglobin (COHb) level, taken for Victim B?
[REQUIRE ANSWER]
(6302)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 117 IS NOT 1, THEN SKIP TO QUESTION 119]

Q.118

What was the level? This number is usually expressed as a percentage.
INTERVIEWER: Please enter "999" if they respondent doesn't know or refuses to answer. Do not
include the percent sign (%).
[REQUIRE ANSWER]
______ (6303-6305)

OMB Control Number 3041-0029

Q.119

Was any further treatment recommended by the hospital staff or sought by the victim after
they were discharged?
[REQUIRE ANSWER]
(6306)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 119 IS NOT 1, THEN SKIP TO QUESTION 137]

Q.120

What treatment was recommended?
[REQUIRE ANSWER]
____________________________________________________________________________

(6307-6506)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 129]

Q.121

INTERVIEWER: The next set of questions is for victims of FIRE or CONTACT BURN-related injuries.
What was the Victim B doing when the burn was sustained?

[REQUIRE ANSWER]
(6507)

q1
q2
q3
q4

Refilling tank
Passing by generator
Other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 121 IS NOT 3, THEN SKIP TO QUESTION 123]

OMB Control Number 3041-0029

Q.122

Can you describe what the victim was doing?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.123

(6508-6657)

For Victim B, what body part was burned?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.124

(6658-6807)

How large was the overall burn area?
INTERVIEWER: Please enter answer as either % of skin surface / L x W in inches; Enter "Do not
known" if unknown or refusal.

[REQUIRE ANSWER]
____________________________________________________________________________

Q.125

(6808-6857)

What was the most severe level of burn: 1st Degree burn (reddening), 2nd Degree burn
(blistering) or 3rd Degree burn (full skin thickness burn)?
[REQUIRE ANSWER]
(6858)

q1
q2
q3
q4

1st Degree Burn
2nd Degree Burn
3rd Degree Burn
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 125 IS 4, THEN SKIP TO QUESTION 127]

OMB Control Number 3041-0029

Q.126

About what fraction of the total burn area was a [ANSWER TO Q. 125] - One quarter, One half,
Three Quarters, or Whole burn area?
[REQUIRE ANSWER]
(6859)

q1
q2
q3
q4
q5
Q.127

1/4 of burn area
1/2 of burn area
3/4 of burn area
whole burn area
Don't Know / Refuse

Which of the following best describes how was Victim B medically treated?
INTERVIEWER: Please read to respondent and check one.

[REQUIRE ANSWER]
(6860)

q1
q2
q3
q4
Q.128

treated and released
admitted to hospital
transferred to burn unit
Don't Know / Refuse

How was the burn treated? (e.g. bandages and topical antibiotics; skin graft; etc.)
[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 2, THEN SKIP TO QUESTION 136]

OMB Control Number 3041-0029

(6861-6960)

Q.129

INTERVIEWER: The next set of questions is for victims of ELECTRICAL SHOCK injuries.
Where did the electricity enter and exit Victim B's body (what body part)?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.130

(6961-7110)

What did Victim B touch or contact when he/she was shocked?
INTERVIEWER: please check one

[REQUIRE ANSWER]
(7111)

q1
q2
q3
q4
q5

The generator itself
Extension cord connected to the generator
Appliance being powered by generator
Other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 130 IS NOT 4, THEN SKIP TO QUESTION 132]

Q.131

Could you please describe the contact source in detail?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(7112-7261)

Q.132

Please describe the situation when the electric shock took place. For example, was the victim
standing in puddle; plugging in an appliance; did the victim have shoes on; etc.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.133

(7262-7461)

What were the weather conditions?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.134

(7462-7561)

Can you describe Victim B's injury severity?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.135

(7562-7761)

Who rescued the victim?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(7762-7811)

Q.136

What medical treatment was given to Victim B?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.137

(7812-7961)

How long was the victim in the hospital?
INTERVIEWER: Enter answer in DAYS. If "treated and released" the same day enter "0". If unknown or
refusal to answer enter "99".
[REQUIRE ANSWER]
______ (7962-7964)

Q.138

What is the current status and prognosis for Victim B?

[REQUIRE ANSWER]
____________________________________________________________________________

(7965-8164)

[A - IF THE ANSWER TO QUESTION 18 IS 1 OR 2 OR 99, THEN SKIP TO QUESTION 298]

Q.139

The following information is about the third victim who we will refer to as “Victim C”. This can
be any one of the victims, I would just ask you to keep this person in mind when answering the
following questions.

Q.140

What was Victim C's age at the time of the incident?
INTERVIEWER: Enter age in years if two years old or older. For a child under two years of age, enter 2
digit months preceded by "2". For example, 3 months old would be "203"; 18 months old would be
"218". Enter "999" for "Don't know / Refuse".
[REQUIRE ANSWER]
______ (8165-8167)

OMB Control Number 3041-0029

Q.141

Is Victim C male or female?
[REQUIRE ANSWER]
(8168)

q 1 Male
q 2 Female
q 3 Don't Know / Refuse
Q.142

What is your relationship to Victim C?
INTERVIEWER: Enter "Self" if the respondent is "Victim C".
[REQUIRE ANSWER]
____________________________________________________________________________

Q.143

(8169-8188)

Did the injury to Victim C occur while the victim was outside or within some type of structure?
[REQUIRE ANSWER]
(8189)

q 1 Outside
q 2 Inside
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 143 IS NOT 2, THEN SKIP TO QUESTION 156]

OMB Control Number 3041-0029

Q.144

I would like to read you a list, would you select the one that best describes the structure where
victim was located:
INTERVIEWER: Please read list through #16
[REQUIRE ANSWER]
(8190-8191)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
none of the above
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 144 IS NOT 17, THEN SKIP TO QUESTION 146]

Q.145

Can you describe the location of the victim at time of the injury?
[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 174]

OMB Control Number 3041-0029

(8192-8341)

Q.146

INTERVIEWER: The next set of questions is for victims of CARBON MONOXIDE injuries.
Where was Victim C located in the structure at the time of the incident?
floor level and room that the victim was located in if known.

Please specify what

[REQUIRE ANSWER]
____________________________________________________________________________

Q.147

(8342-8441)

Can you tell me about how long was the victim exposed to the CO?
INTERVIEWER: Please express this time in hours or fractional hours. For example, 90 minutes = 1.5
hours; 15 minutes = 0.25 hours. Please enter "99" if the respondent states that they do not know or
refuse to answer.
[REQUIRE ANSWER]
________________ (8442-8449)

Q.148

At Victim C's location at the time of the incident, were one or more windows open?
[REQUIRE ANSWER]
(8450)

q1
q2
q3
q4

Yes
No
Structure has no windows
Don't Know
[A - IF THE ANSWER TO QUESTION 148 IS NOT 1, THEN SKIP TO QUESTION 152]

Q.149

How many windows?
INTERVIEWER: Enter "99" for "Do not know" or refusal.
[REQUIRE ANSWER]
____ (8451-8452)
[A - IF THE ANSWER TO QUESTION 149 IS NOT 1, THEN SKIP TO QUESTION 151]

OMB Control Number 3041-0029

Q.150

From the following list, how open would you say the window at the victim's location was at the
time of the incident?
INTERVIEWER: please read list to respondent.

[REQUIRE ANSWER]
(8453)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 149 IS 1 OR 99, THEN SKIP TO QUESTION 152]

Q.151

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
[REQUIRE ANSWER]
(8454)

q1
q2
q3
q4
q5
q6
q7
Q.152

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at Victim C’s location?
[REQUIRE ANSWER]
(8455)

q1
q2
q3
q4

Yes
No
Structure has no door
Don't Know
[A - IF THE ANSWER TO QUESTION 152 IS NOT 1, THEN SKIP TO QUESTION 154]

OMB Control Number 3041-0029

Q.153

How open would you say the door was?
[REQUIRE ANSWER]
(8456)

q1
q2
q3
q4
Q.154

wide open
partially open
open just a crack
Don't Know / Refuse

Was there any other type of ventilation at Victim C's location such as a fan running or an air
conditioner?
[REQUIRE ANSWER]
(8457)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 154 IS NOT 1, THEN SKIP TO QUESTION 156]

Q.155

What other type of ventilation was used at Victim C's location?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.156

(8458-8557)

Can you tell me about the general health status of Victim C at time of incident? Please identify
any drugs/medications/alcohol being taken at the time of incident.

[REQUIRE ANSWER]
____________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 162]

Q.157

Is Victim C currently a smoker?
[REQUIRE ANSWER]
(8758)

OMB Control Number 3041-0029

(8558-8757)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 157 IS NOT 1, THEN SKIP TO QUESTION 160]

Q.158

What type of product does Victim C primarily smoke - Cigarettes, Cigars or Pipes?
[REQUIRE ANSWER]
(8759)

q1
q2
q3
q4

Cigarettes
Cigars
Pipes
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 158 IS 4, THEN SKIP TO QUESTION 160]

Q.159

How many [ANSWER TO Q. 158] would you say Victim C smoke per day?
INTERVIEWER: Enter "99" for "Do not know" or refusal to answer.
[REQUIRE ANSWER]
____ (8760-8761)

Q.160

Returning to the carbon monoxide exposure, could you please describe Victim C’s
symptoms?
[REQUIRE ANSWER]
____________________________________________________________________________

OMB Control Number 3041-0029

(8762-8961)

Q.161

[ANSWER TO Q. 160]
INTERVIEWER: Check all that apply from description above – for those not checked ask respondent if
they know if Victim C experienced any of the other specific symptoms:
INTERVIEWER: Hit E
" nter" after each choice. Hit "Enter" again of click "Next" to move on to the next
question. Please note that unselected choices are inBOLD, selected choices are innon-BOLD.
[REQUIRE ANSWER]
(8962-8979)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
Q.162

None
Headache
Fatigue
Sleepy
Disorientation
Nausea
Vomiting
Chest Pains
Shortness of Breath
Loss of Consciousness
Don't know / Refuse

Did Victim C receive treatment at the scene?
[REQUIRE ANSWER]
(8980)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 162 IS NOT 1, THEN SKIP TO QUESTION 164]

OMB Control Number 3041-0029

Q.163

Please describe the treatment Victim C received at the scene and who treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.164

(8981-9180)

Was treatment received en route to Emergency Room?
[REQUIRE ANSWER]
(9181)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 164 IS NOT 1, THEN SKIP TO QUESTION 166]

Q.165

Please describe the treatment Victim C received en route to the Emergency Room and who
treated the victim.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.166

(9182-9381)

Was treatment received at Emergency Room?
[REQUIRE ANSWER]
(9382)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 166 IS NOT 1, THEN SKIP TO QUESTION 170]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 172]

Q.167

Was oxygen given by face mask to Victim C? This may have been referred to as "100%
normobaric oxygen" or "NBO".
[REQUIRE ANSWER]
(9383)

q 1 Yes

OMB Control Number 3041-0029

q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 167 IS NOT 1, THEN SKIP TO QUESTION 169]

Q.168

How long was the victim given oxygen?

[REQUIRE ANSWER]
____________________________________________________________________________

Q.169

(9384-9433)

Did Victim C receive treatment in a hyperbaric chamber? This may have been referred to as
"hyperbaric oxygen" or "HBO".
[REQUIRE ANSWER]
(9434)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
Q.170

Was a blood CO level, or carboxyhemoglobin (COHb) level, taken for Victim C?
[REQUIRE ANSWER]
(9435)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 170 IS NOT 1, THEN SKIP TO QUESTION 172]

Q.171

What was the level? This number is usually expressed as a percentage.
INTERVIEWER: Please enter "999" if they respondent doesn't know or refuses to answer. Do not
include the percent sign (%).
[REQUIRE ANSWER]
______ (9436-9438)

OMB Control Number 3041-0029

Q.172

Was any further treatment recommended by the hospital staff or sought by the victim after
they were discharged?
[REQUIRE ANSWER]
(9439)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 172 IS NOT 1, THEN SKIP TO QUESTION 190]

Q.173

What treatment was recommended?
[REQUIRE ANSWER]
____________________________________________________________________________

(9440-9639)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 182]

Q.174

INTERVIEWER: The next set of questions is for victims of FIRE or CONTACT BURN-related injuries.
What was the Victim C doing when the burn was sustained?

[REQUIRE ANSWER]
(9640)

q1
q2
q3
q4

Refilling tank
Passing by generator
Other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 174 IS NOT 3, THEN SKIP TO QUESTION 176]

OMB Control Number 3041-0029

Q.175

Can you describe what the victim was doing?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.176

(9641-9790)

For Victim C, what body part was burned?
[REQUIRE ANSWER]
____________________________________________________________________________

Q.177

(9791-9940)

How large was the overall burn area?
INTERVIEWER: Please enter answer as either % of skin surface / L x W in inches; Enter "Do not
known" if unknown or refusal.

[REQUIRE ANSWER]
____________________________________________________________________________

Q.178

(9941-9990)

What was the most severe level of burn: 1st Degree burn (reddening), 2nd Degree burn
(blistering) or 3rd Degree burn (full skin thickness burn)?
[REQUIRE ANSWER]
(9991)

q1
q2
q3
q4

1st Degree Burn
2nd Degree Burn
3rd Degree Burn
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 178 IS 4, THEN SKIP TO QUESTION 180]

OMB Control Number 3041-0029

Q.179

About what fraction of the total burn area was a [ANSWER TO Q. 178] - One quarter, One half,
Three Quarters, or Whole burn area?
[REQUIRE ANSWER]
(9992)

q1
q2
q3
q4
q5
Q.180

1/4 of burn area
1/2 of burn area
3/4 of burn area
whole burn area
Don't Know / Refuse

Which of the following best describes how was Victim C medically treated?
INTERVIEWER: Please read to respondent and check one.

[REQUIRE ANSWER]
(9993)

q1
q2
q3
q4
Q.181

treated and released
admitted to hospital
transferred to burn unit
Don't Know / Refuse

How was the burn treated? (e.g. bandages and topical antibiotics; skin graft; etc.)
[REQUIRE ANSWER]
___________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 2, THEN SKIP TO QUESTION 189]

OMB Control Number 3041-0029

(9994-10093)

Q.182

INTERVIEWER: The next set of questions is for victims of ELECTRICAL SHOCK injuries.
Where did the electricity enter and exit Victim C's body (what body part)?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.183

(10094-10243)

What did Victim C touch or contact when he/she was shocked?
INTERVIEWER: please check one

[REQUIRE ANSWER]
(10244)

q1
q2
q3
q4
q5

The generator itself
Extension cord connected to the generator
Appliance being powered by generator
Other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 183 IS NOT 4, THEN SKIP TO QUESTION 185]

Q.184

Could you please describe the contact source in detail?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(10245-10394)

Q.185

Please describe the situation when the electric shock took place. For example, was the victim
standing in puddle; plugging in an appliance; did the victim have shoes on; etc.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.186

(10395-10594)

What were the weather conditions?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.187

(10595-10694)

Can you describe Victim C's injury severity?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.188

(10695-10894)

Who rescued the victim?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(10895-10944)

Q.189

What medical treatment was given to Victim C?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.190

(10945-11094)

How long was the victim in the hospital?
INTERVIEWER: Enter answer in DAYS. If "treated and released" the same day enter "0". If unknown or
refusal to answer enter "99".
[REQUIRE ANSWER]
______ (11095-11097)

Q.191

What is the current status and prognosis for Victim C?

[REQUIRE ANSWER]
__________________________________________________________________________

(11098-11297)

[A - IF THE ANSWER TO QUESTION 18 IS 1 OR 2 OR 3 OR 99, THEN SKIP TO QUESTION 298]

Q.192

The following information is about the forth victim who we will refer to as “Victim D”. This can
be any one of the victims, I would just ask you to keep this person in mind when answering the
following questions.

Q.193

What was Victim D’s age at the time of the incident?
INTERVIEWER: Enter age in years if two years old or older. For a child under two years of age, enter 2
digit months preceded by "2". For example, 3 months old would be "203"; 18 months old would be
"218". Enter "999" for "Don't know / Refuse".
[REQUIRE ANSWER]
______ (11298-11300)

OMB Control Number 3041-0029

Q.194

Is Victim D male or female?
[REQUIRE ANSWER]
(11301)

q 1 Male
q 2 Female
q 3 Don't Know / Refuse
Q.195

What is your relationship to Victim D?
INTERVIEWER: Enter "Self" if the respondent is "Victim D".
[REQUIRE ANSWER]
__________________________________________________________________________

Q.196

(11302-11321)

Did the injury to Victim D occur while the victim was outside or within some type of structure?
[REQUIRE ANSWER]
(11322)

q 1 Outside
q 2 Inside
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 196 IS NOT 2, THEN SKIP TO QUESTION 209]

OMB Control Number 3041-0029

Q.197

I would like to read you a list, would you select the one that best describes the structure where
victim was located:
INTERVIEWER: Please read list through #16
[REQUIRE ANSWER]
(11323-11324)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
none of the above
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 197 IS NOT 17, THEN SKIP TO QUESTION 199]

Q.198

Can you describe the location of the victim at time of the injury?
[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 227]

OMB Control Number 3041-0029

(11325-11474)

Q.199

INTERVIEWER: The next set of questions is for victims of CARBON MONOXIDE injuries.
Where was Victim D located in the structure at the time of the incident?
floor level and room that the victim was located in if known.

Please specify what

[REQUIRE ANSWER]
__________________________________________________________________________

Q.200

(11475-11574)

Can you tell me about how long was the victim exposed to the CO?
INTERVIEWER: Please express this time in hours or fractional hours. For example, 90 minutes = 1.5
hours; 15 minutes = 0.25 hours. Please enter "99" if the respondent states that they do not know or
refuse to answer.
[REQUIRE ANSWER]
________________ (11575-11582)

Q.201

At Victim D's location at the time of the incident, were one or more windows open?
[REQUIRE ANSWER]
(11583)

q1
q2
q3
q4

Yes
No
Structure has no windows
Don't Know
[A - IF THE ANSWER TO QUESTION 201 IS NOT 1, THEN SKIP TO QUESTION 205]

Q.202

How many windows?
INTERVIEWER: Enter "99" for "Do not know" or refusal.
[REQUIRE ANSWER]
____ (11584-11585)
[A - IF THE ANSWER TO QUESTION 202 IS NOT 1, THEN SKIP TO QUESTION 204]

OMB Control Number 3041-0029

Q.203

From the following list, how open would you say the window at the victim's location was at the
time of the incident?
INTERVIEWER: please read list to respondent.

[REQUIRE ANSWER]
(11586)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 202 IS 1 OR 99, THEN SKIP TO QUESTION 205]

Q.204

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
[REQUIRE ANSWER]
(11587)

q1
q2
q3
q4
q5
q6
q7
Q.205

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at Victim D’s location?
[REQUIRE ANSWER]
(11588)

q1
q2
q3
q4

Yes
No
Structure has no door
Don't Know
[A - IF THE ANSWER TO QUESTION 205 IS NOT 1, THEN SKIP TO QUESTION 207]

OMB Control Number 3041-0029

Q.206

How open would you say the door was?
[REQUIRE ANSWER]
(11589)

q1
q2
q3
q4
Q.207

wide open
partially open
open just a crack
Don't Know / Refuse

Was there any other type of ventilation at Victim D's location such as a fan running or an air
conditioner?
[REQUIRE ANSWER]
(11590)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 207 IS NOT 1, THEN SKIP TO QUESTION 209]

Q.208

What other type of ventilation was used at Victim D's location?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.209

(11591-11690)

Can you tell me about the general health status of Victim D at time of incident? Please identify
any drugs/medications/alcohol being taken at the time of incident.

[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 215]

Q.210

Is Victim D currently a smoker?
[REQUIRE ANSWER]
(11891)

OMB Control Number 3041-0029

(11691-11890)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 210 IS NOT 1, THEN SKIP TO QUESTION 213]

Q.211

What type of product does Victim D primarily smoke - Cigarettes, Cigars or Pipes?
[REQUIRE ANSWER]
(11892)

q1
q2
q3
q4

Cigarettes
Cigars
Pipes
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 211 IS 4, THEN SKIP TO QUESTION 213]

Q.212

How many [ANSWER TO Q. 211] would you say Victim D smoke per day?
INTERVIEWER: Enter "99" for "Do not know" or refusal to answer.
[REQUIRE ANSWER]
____ (11893-11894)

Q.213

Returning to the carbon monoxide exposure, could you please describe Victim D’s
symptoms?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(11895-12094)

Q.214

[ANSWER TO Q. 213]
INTERVIEWER: Check all that apply from description above – for those not checked ask respondent if
they know if Victim D experienced any of the other specific symptoms:
INTERVIEWER: Hit E
" nter" after each choice. Hit "Enter" again of click "Next" to move on to the next
question. Please note that unselected choices are inBOLD, selected choices are innon-BOLD.
[REQUIRE ANSWER]
(12095-12112)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
Q.215

None
Headache
Fatigue
Sleepy
Disorientation
Nausea
Vomiting
Chest Pains
Shortness of Breath
Loss of Consciousness
Don't know / Refuse

Did Victim D receive treatment at the scene?
[REQUIRE ANSWER]
(12113)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 215 IS NOT 1, THEN SKIP TO QUESTION 217]

OMB Control Number 3041-0029

Q.216

Please describe the treatment Victim D received at the scene and who treated the victim.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.217

(12114-12313)

Was treatment received en route to Emergency Room?
[REQUIRE ANSWER]
(12314)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 217 IS NOT 1, THEN SKIP TO QUESTION 219]

Q.218

Please describe the treatment Victim D received en route to the Emergency Room and who
treated the victim.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.219

(12315-12514)

Was treatment received at Emergency Room?
[REQUIRE ANSWER]
(12515)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 219 IS NOT 1, THEN SKIP TO QUESTION 223]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 225]

Q.220

Was oxygen given by face mask to Victim D? This may have been referred to as "100%
normobaric oxygen" or "NBO".
[REQUIRE ANSWER]
(12516)

q 1 Yes

OMB Control Number 3041-0029

q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 220 IS NOT 1, THEN SKIP TO QUESTION 222]

Q.221

How long was the victim given oxygen?

[REQUIRE ANSWER]
__________________________________________________________________________

Q.222

(12517-12566)

Did Victim D receive treatment in a hyperbaric chamber? This may have been referred to as
"hyperbaric oxygen" or "HBO".
[REQUIRE ANSWER]
(12567)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
Q.223

Was a blood CO level, or carboxyhemoglobin (COHb) level, taken for Victim D?
[REQUIRE ANSWER]
(12568)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 223 IS NOT 1, THEN SKIP TO QUESTION 225]

Q.224

What was the level? This number is usually expressed as a percentage.
INTERVIEWER: Please enter "999" if they respondent doesn't know or refuses to answer. Do not
include the percent sign (%).
[REQUIRE ANSWER]
______ (12569-12571)

OMB Control Number 3041-0029

Q.225

Was any further treatment recommended by the hospital staff or sought by the victim after
they were discharged?
[REQUIRE ANSWER]
(12572)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 225 IS NOT 1, THEN SKIP TO QUESTION 243]

Q.226

What treatment was recommended?
[REQUIRE ANSWER]
__________________________________________________________________________

(12573-12772)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 235]

Q.227

INTERVIEWER: The next set of questions is for victims of FIRE or CONTACT BURN-related injuries.
What was the Victim D doing when the burn was sustained?

[REQUIRE ANSWER]
(12773)

q1
q2
q3
q4

Refilling tank
Passing by generator
Other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 227 IS NOT 3, THEN SKIP TO QUESTION 229]

OMB Control Number 3041-0029

Q.228

Can you describe what the victim was doing?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.229

(12774-12923)

For Victim D, what body part was burned?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.230

(12924-13073)

How large was the overall burn area?
INTERVIEWER: Please enter answer as either % of skin surface / L x W in inches; Enter "Do not
known" if unknown or refusal.

[REQUIRE ANSWER]
__________________________________________________________________________

Q.231

(13074-13123)

What was the most severe level of burn: 1st Degree burn (reddening), 2nd Degree burn
(blistering) or 3rd Degree burn (full skin thickness burn)?
[REQUIRE ANSWER]
(13124)

q1
q2
q3
q4

1st Degree Burn
2nd Degree Burn
3rd Degree Burn
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 231 IS 4, THEN SKIP TO QUESTION 233]

OMB Control Number 3041-0029

Q.232

About what fraction of the total burn area was a [ANSWER TO Q. 232] - One quarter, One half,
Three Quarters, or Whole burn area?
[REQUIRE ANSWER]
(13125)

q1
q2
q3
q4
q5
Q.233

1/4 of burn area
1/2 of burn area
3/4 of burn area
whole burn area
Don't Know / Refuse

Which of the following best describes how was Victim D medically treated?
INTERVIEWER: Please read to respondent and check one.

[REQUIRE ANSWER]
(13126)

q1
q2
q3
q4
Q.234

treated and released
admitted to hospital
transferred to burn unit
Don't Know / Refuse

How was the burn treated? (e.g. bandages and topical antibiotics; skin graft; etc.)
[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 2, THEN SKIP TO QUESTION 242]

OMB Control Number 3041-0029

(13127-13226)

Q.235

INTERVIEWER: The next set of questions is for victims of ELECTRICAL SHOCK injuries.
Where did the electricity enter and exit Victim D's body (what body part)?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.236

(13227-13376)

What did Victim D touch or contact when he/she was shocked?
INTERVIEWER: please check one

[REQUIRE ANSWER]
(13377)

q1
q2
q3
q4
q5

The generator itself
Extension cord connected to the generator
Appliance being powered by generator
Other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 236 IS NOT 4, THEN SKIP TO QUESTION 238]

Q.237

Could you please describe the contact source in detail?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(13378-13527)

Q.238

Please describe the situation when the electric shock took place. For example, was the victim
standing in puddle; plugging in an appliance; did the victim have shoes on; etc.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.239

(13528-13727)

What were the weather conditions?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.240

(13728-13827)

Can you describe Victim D's injury severity?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.241

(13828-14027)

Who rescued the victim?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(14028-14077)

Q.242

What medical treatment was given to Victim D?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.243

(14078-14227)

How long was the victim in the hospital?
INTERVIEWER: Enter answer in DAYS. If "treated and released" the same day enter "0". If unknown or
refusal to answer enter "99".
[REQUIRE ANSWER]
______ (14228-14230)

Q.244

What is the current status and prognosis for Victim D?

[REQUIRE ANSWER]
__________________________________________________________________________

(14231-14430)

[A - IF THE ANSWER TO QUESTION 18 IS 1 OR 2 OR 3 OR 4 OR 99, THEN SKIP TO QUESTION 298]

Q.245

The following information is about the fifth victim who we will refer to as “Victim E”. This can
be any one of the victims, I would just ask you to keep this person in mind when answering the
following questions.

Q.246

What was Victim E’s age at the time of the incident?
INTERVIEWER: Enter age in years if two years old or older. For a child under two years of age, enter 2
digit months preceded by "2". For example, 3 months old would be "203"; 18 months old would be
"218". Enter "999" for "Don't know / Refuse".
[REQUIRE ANSWER]
______ (14431-14433)

OMB Control Number 3041-0029

Q.247

Is Victim E male or female?
[REQUIRE ANSWER]
(14434)

q 1 Male
q 2 Female
q 3 Don't Know / Refuse
Q.248

What is your relationship to Victim E?
INTERVIEWER: Enter "Self" if the respondent is "Victim E".
[REQUIRE ANSWER]
__________________________________________________________________________

Q.249

(14435-14454)

Did the injury to Victim E occur while the victim was outside or within some type of structure?
[REQUIRE ANSWER]
(14455)

q 1 Outside
q 2 Inside
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 249 IS NOT 2, THEN SKIP TO QUESTION 262]

OMB Control Number 3041-0029

Q.250

I would like to read you a list, would you select the one that best describes the structure where
victim was located:
INTERVIEWER: Please read list through #16
[REQUIRE ANSWER]
(14456-14457)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18

the living space of a single family, detached home
the basement of a single family, detached home
the living space of a town house / row house / duplex (attached home)
the basement of a town house / row house / duplex (attached home)
apartment in apartment building
trailer home
RV
boat
tent
attached garage
detached garage
crawlspace
carport
enclosed porch (sealed from the environment - for example, glassed-in porch)
partially enclosed porch (a screened-in porch with some type of weather-proof roof)
shed
none of the above
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 250 IS NOT 17, THEN SKIP TO QUESTION 252]

Q.251

Can you describe the location of the victim at time of the injury?
[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 280]

OMB Control Number 3041-0029

(14458-14607)

Q.252

INTERVIEWER: The next set of questions is for victims of CARBON MONOXIDE injuries.
Where was Victim E located in the structure at the time of the incident?
floor level and room that the victim was located in if known.

Please specify what

[REQUIRE ANSWER]
__________________________________________________________________________

Q.253

(14608-14707)

Can you tell me about how long was the victim exposed to the CO?
INTERVIEWER: Please express this time in hours or fractional hours. For example, 90 minutes = 1.5
hours; 15 minutes = 0.25 hours. Please enter "99" if the respondent states that they do not know or
refuse to answer.
[REQUIRE ANSWER]
________________ (14708-14715)

Q.254

At Victim E's location at the time of the incident, were one or more windows open?
[REQUIRE ANSWER]
(14716)

q1
q2
q3
q4

Yes
No
Structure has no windows
Don't Know
[A - IF THE ANSWER TO QUESTION 254 IS NOT 1, THEN SKIP TO QUESTION 258]

Q.255

How many windows?
INTERVIEWER: Enter "99" for "Do not know" or refusal.
[REQUIRE ANSWER]
____ (14717-14718)
[A - IF THE ANSWER TO QUESTION 255 IS NOT 1, THEN SKIP TO QUESTION 257]

OMB Control Number 3041-0029

Q.256

From the following list, how open would you say the window at the victim's location was at the
time of the incident?
INTERVIEWER: please read list to respondent.

[REQUIRE ANSWER]
(14719)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 255 IS 1 OR 99, THEN SKIP TO QUESTION 258]

Q.257

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
[REQUIRE ANSWER]
(14720)

q1
q2
q3
q4
q5
q6
q7
Q.258

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at Victim E’s location?
[REQUIRE ANSWER]
(14721)

q1
q2
q3
q4

Yes
No
Structure has no door
Don't Know
[A - IF THE ANSWER TO QUESTION 258 IS NOT 1, THEN SKIP TO QUESTION 260]

Q.259

How open would you say the door was?
[REQUIRE ANSWER]
(14722)

q 1 wide open

OMB Control Number 3041-0029

q 2 partially open
q 3 open just a crack
q 4 Don't Know / Refuse
Q.260

Was there any other type of ventilation at Victim E's location such as a fan running or an air
conditioner?
[REQUIRE ANSWER]
(14723)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 260 IS NOT 1, THEN SKIP TO QUESTION 262]

Q.261

What other type of ventilation was used at Victim E's location?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.262

(14724-14823)

Can you tell me about the general health status of Victim E at time of incident? Please identify
any drugs/medications/alcohol being taken at the time of incident.

[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 268]

Q.263

Is Victim E currently a smoker?
[REQUIRE ANSWER]
(15024)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 263 IS NOT 1, THEN SKIP TO QUESTION 266]

OMB Control Number 3041-0029

(14824-15023)

Q.264

What type of product does Victim E primarily smoke - Cigarettes, Cigars or Pipes?
[REQUIRE ANSWER]
(15025)

Cigarettes
Cigars
Pipes
Don't Know / Refuse

q1
q2
q3
q4

[A - IF THE ANSWER TO QUESTION 264 IS 4, THEN SKIP TO QUESTION 266]

Q.265

How many [ANSWER TO Q. 264] would you say Victim E smoke per day?
INTERVIEWER: Enter "99" for "Do not know" or refusal to answer.
[REQUIRE ANSWER]
____ (15026-15027)

Q.266

Returning to the carbon monoxide exposure, could you please describe Victim E’s
symptoms?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.267

(15028-15227)

[ANSWER TO Q. 266]
INTERVIEWER: Check all that apply from description above – for those not checked ask respondent if
they know if Victim E experienced any of the other specific symptoms:
INTERVIEWER: Hit E
" nter" after each choice. Hit "Enter" again of click "Next" to move on to the next
question. Please note that unselected choices are inBOLD, selected choices are innon-BOLD.
[REQUIRE ANSWER]
(15228-15245)

q 01
q 02
q 03
q 04
q 05

None
Headache
Fatigue
Sleepy
Disorientation

OMB Control Number 3041-0029

q 06
q 07
q 08
q 09
q 10
q 11
Q.268

Nausea
Vomiting
Chest Pains
Shortness of Breath
Loss of Consciousness
Don't know / Refuse

Did Victim E receive treatment at the scene?
[REQUIRE ANSWER]
(15246)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 268 IS NOT 1, THEN SKIP TO QUESTION 270]

Q.269

Please describe the treatment Victim E received at the scene and who treated the victim.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.270

Was treatment received en route to Emergency Room?
[REQUIRE ANSWER]
(15447)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 270 IS NOT 1, THEN SKIP TO QUESTION 272]

OMB Control Number 3041-0029

(15247-15446)

Q.271

Please describe the treatment Victim E received en route to the Emergency Room and who
treated the victim.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.272

(15448-15647)

Was treatment received at Emergency Room?
[REQUIRE ANSWER]
(15648)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 272 IS NOT 1, THEN SKIP TO QUESTION 276]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 278]

Q.273

Was oxygen given by face mask to Victim E? This may have been referred to as "100%
normobaric oxygen" or "NBO".
[REQUIRE ANSWER]
(15649)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 273 IS NOT 1, THEN SKIP TO QUESTION 275]

Q.274

How long was the victim given oxygen?

[REQUIRE ANSWER]
__________________________________________________________________________

Q.275

(15650-15699)

Did Victim E receive treatment in a hyperbaric chamber? This may have been referred to as
"hyperbaric oxygen" or "HBO".
[REQUIRE ANSWER]
(15700)

OMB Control Number 3041-0029

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
Q.276

Was a blood CO level, or carboxyhemoglobin (COHb) level, taken for Victim E?
[REQUIRE ANSWER]
(15701)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 276 IS NOT 1, THEN SKIP TO QUESTION 278]

Q.277

What was the level? This number is usually expressed as a percentage.
INTERVIEWER: Please enter "999" if they respondent doesn't know or refuses to answer. Do not
include the percent sign (%).
[REQUIRE ANSWER]
______ (15702-15704)

Q.278

Was any further treatment recommended by the hospital staff or sought by the victim after
they were discharged?
[REQUIRE ANSWER]
(15705)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 278 IS NOT 1, THEN SKIP TO QUESTION 296]

OMB Control Number 3041-0029

Q.279

What treatment was recommended?
[REQUIRE ANSWER]
__________________________________________________________________________

(15706-15905)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 3, THEN SKIP TO QUESTION 288]

Q.280

INTERVIEWER: The next set of questions is for victims of FIRE or CONTACT BURN-related injuries.
What was the Victim E doing when the burn was sustained?

[REQUIRE ANSWER]
(15906)

q1
q2
q3
q4

Refilling tank
Passing by generator
Other
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 280 IS NOT 3, THEN SKIP TO QUESTION 282]

Q.281

Can you describe what the victim was doing?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.282

(15907-16056)

For Victim E, what body part was burned?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(16057-16206)

Q.283

How large was the overall burn area?
INTERVIEWER: Please enter answer as either % of skin surface / L x W in inches; Enter "Do not
known" if unknown or refusal.

[REQUIRE ANSWER]
__________________________________________________________________________

Q.284

(16207-16256)

What was the most severe level of burn: 1st Degree burn (reddening), 2nd Degree burn
(blistering) or 3rd Degree burn (full skin thickness burn)?
[REQUIRE ANSWER]
(16257)

q1
q2
q3
q4

1st Degree Burn
2nd Degree Burn
3rd Degree Burn
Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 284 IS 4, THEN SKIP TO QUESTION 286]

Q.285

About what fraction of the total burn area was a [ANSWER TO Q. 284] - One quarter, One half,
Three Quarters, or Whole burn area?
[REQUIRE ANSWER]
(16258)

q1
q2
q3
q4
q5
Q.286

1/4 of burn area
1/2 of burn area
3/4 of burn area
whole burn area
Don't Know / Refuse

Which of the following best describes how was Victim E medically treated?
INTERVIEWER: Please read to respondent and check one.

[REQUIRE ANSWER]
(16259)

q 1 treated and released
q 2 admitted to hospital

OMB Control Number 3041-0029

q 3 transferred to burn unit
q 4 Don't Know / Refuse
Q.287

How was the burn treated? (e.g. bandages and topical antibiotics; skin graft; etc.)
[REQUIRE ANSWER]
__________________________________________________________________________

(16260-16359)

[A - IF THE ANSWER TO QUESTION 13 IS NOT 2, THEN SKIP TO QUESTION 295]

Q.288

INTERVIEWER: The next set of questions is for victims of ELECTRICAL SHOCK injuries.
Where did the electricity enter and exit Victim E's body (what body part)?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.289

What did Victim E touch or contact when he/she was shocked?
INTERVIEWER: please check one

[REQUIRE ANSWER]
(16510)

q1
q2
q3
q4
q5

The generator itself
Extension cord connected to the generator
Appliance being powered by generator
Other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 289 IS NOT 4, THEN SKIP TO QUESTION 291]

OMB Control Number 3041-0029

(16360-16509)

Q.290

Could you please describe the contact source in detail?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.291

(16511-16660)

Please describe the situation when the electric shock took place. For example, was the victim
standing in puddle; plugging in an appliance; did the victim have shoes on; etc.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.292

(16661-16860)

What were the weather conditions?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.293

(16861-16960)

Can you describe Victim E's injury severity?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.294

(16961-17160)

Who rescued the victim?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(17161-17210)

Q.295

What medical treatment was given to Victim E?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.296

(17211-17360)

How long was the victim in the hospital?
INTERVIEWER: Enter answer in DAYS. If "treated and released" the same day enter "0". If unknown or
refusal to answer enter "99".
[REQUIRE ANSWER]
______ (17361-17363)

Q.297

What is the current status and prognosis for Victim E?

[REQUIRE ANSWER]
__________________________________________________________________________

Q.298

(17364-17563)

INTERVIEWER say: "The next series of questions will be about the generator involved that was in the
incident. We will start with some questions about the generator's location at the time of the incident. We
will then finish up with some questions about the generator itself."
[D - IF THE ANSWER TO QUESTION 24 IS 1-8, THEN SKIP TO QUESTION 300]
[D - IF THE ANSWER TO QUESTION 36 IS 1-8, THEN SKIP TO QUESTION 300]
[D - IF THE ANSWER TO QUESTION 91 IS 1-8, THEN SKIP TO QUESTION 300]
[D - IF THE ANSWER TO QUESTION 144 IS 1-8, THEN SKIP TO QUESTION 300]
[D - IF THE ANSWER TO QUESTION 197 IS 1-8, THEN SKIP TO QUESTION 300]
[D - IF THE ANSWER TO QUESTION 250 IS 1-8, THEN SKIP TO QUESTION 300]
[A - IF THE ANSWER TO QUESTION 4 IS 1, THEN SKIP TO QUESTION 315]

Q.299

blank

Q.300

What is the approximate age (yrs.) of the structure?
INTERVIEWER: Please enter "999" for "don't know" or refuse.
______ (17564-17566)

OMB Control Number 3041-0029

Q.301

What is the approximate size (sq. ft.) of the structure where the incident occured? If the
incident occured in an apartment or condominium please only specify the size of the specific
unit not the whole building.
INTERVIEWER: Please enter"0" (zero) for "don't know" or refuse.
____________ (17567-17572)
[D - IF THE ANSWER TO QUESTION 24 IS 1-5, THEN SKIP TO QUESTION 303]
[D - IF THE ANSWER TO QUESTION 36 IS 1-5, THEN SKIP TO QUESTION 303]
[D - IF THE ANSWER TO QUESTION 91 IS 1-5, THEN SKIP TO QUESTION 303]
[D - IF THE ANSWER TO QUESTION 144 IS 1-5, THEN SKIP TO QUESTION 303]
[D - IF THE ANSWER TO QUESTION 197 IS 1-5, THEN SKIP TO QUESTION 303]
[D - IF THE ANSWER TO QUESTION 250 IS 1-5, THEN SKIP TO QUESTION 303]
[A - IF THE ANSWER TO QUESTION 4 IS 1, THEN SKIP TO QUESTION 305]

Q.302

blank
__ (17573)

Q.303

How many floors are there in the house? Please include the basement as a floor if there is
one.
INTERVIEWER: Please enter "0" (zero) for "don't know" or refuse.
____ (17574-17575)

Q.304

Is the home where the incident occured a split level home?
(17576)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 24 IS 17 OR 19, THEN SKIP TO QUESTION 315]
[A - IF THE ANSWER TO QUESTION 13 IS NOT 1, THEN SKIP TO QUESTION 315]

Q.305

At the time of the incident, were there any windows open at the location of the generator?
(17577)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 305 IS NOT 1, THEN SKIP TO QUESTION 309]

OMB Control Number 3041-0029

Q.306

How many windows were fully or partially open?
INTERVIEWER: Enter "99" for "Don't know" or refuse.
____ (17578-17579)
[A - IF THE ANSWER TO QUESTION 306 IS NOT 1, THEN SKIP TO QUESTION 308]

Q.307

From the following list, how open would you say the window was at the time of the incident?
INTERVIEWER: Please read list to respondent.
(17580)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't know / refuse
[A - IF THE ANSWER TO QUESTION 306 IS 1 OR 99, THEN SKIP TO QUESTION 309]

Q.308

From the following list, could you tell me which best describes the window situation at the
location of the victim at the time of the incident?
INTERVIEWER: Please read list to respondent.
(17581)

q1
q2
q3
q4
q5
q6
q7
Q.309

All the open windows were wide open
One or more of the open windows were wide open, others were only partially open
One or more of the open windows were wide open, others were open only a crack
All the open windows were partially open
One or more of the open windows were partially open, others were open only a crack
All the open windows were open only a crack
Don't Know / Refuse

At the time of the incident, was there a door open to the outside at the generator's location?
(17582)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 309 IS NOT 1, THEN SKIP TO QUESTION 311]

OMB Control Number 3041-0029

Q.310

How open would you say the door was?
INTERVIEWER: Please read list to respondent.
(17583)

q1
q2
q3
q4

wide open
partially open
open just a crack
Don't know / refuse
[A - IF THE ANSWER TO QUESTION 24 IS NOT 10 OR 11, THEN SKIP TO QUESTION 313]

Q.311

Was the garage door open?
(17584)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 311 IS NOT 1, THEN SKIP TO QUESTION 313]

Q.312

How open would you say the garage door was?
INTERVIEWER: Please read list to respondent.
(17585)

q1
q2
q3
q4
Q.313

wide open
partially open
open just a crack
Don't know / refuse

Was there any other type of ventilation at the generator's location such as a fan running or an
air conditioner?
(17586)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 313 IS NOT 1, THEN SKIP TO QUESTION 315]

OMB Control Number 3041-0029

Q.314

What other type of ventilation was used at the generator's location?
__________________________________________________________________________

Q.315

(17587-17686)

What type of generator was involved, a portable generator or a fixed-site stationary model?

[REQUIRE ANSWER]
(17687)

q 1 portable
q 2 fixed site stationary
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 315 IS NOT 2, THEN SKIP TO QUESTION 318]

Q.316

Do you know who installed the generator?
INTERVIEWER --> Do not read choices unless necessary.
[REQUIRE ANSWER]
(17688)

q1
q2
q3
q4
q5

professional electrician
owner
local handyman
other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 316 IS NOT 4, THEN SKIP TO QUESTION 321]

Q.317

Could you describe who installed the generator?
[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 24 IS NOT 17, THEN SKIP TO QUESTION 321]

OMB Control Number 3041-0029

(17689-17708)

Q.318

How close was the generator to the structure where the victims were found?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.319

(17709-17758)

Were there any open or partially open windows, doors, vents (like a dryer duct or exhaust fan
outlet) or a window air conditioner near the generator?
[REQUIRE ANSWER]
(17759)

q 1 Yes
q 2 No
q 3 Don't Know
[A - IF THE ANSWER TO QUESTION 319 IS NOT 1, THEN SKIP TO QUESTION 321]

Q.320

Please explain.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.321

What type of fuel did the generator use?
[REQUIRE ANSWER]
(17910)

q1
q2
q3
q4
q5
q6

gasoline
propane
natural gas
diesel
kerosene
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 321 IS 6, THEN SKIP TO QUESTION 323]

OMB Control Number 3041-0029

(17760-17909)

Q.322

Was the generator originally designed for [ANSWER TO Q. 321] use? If not, what type of fuel
was it originally designed for?
[REQUIRE ANSWER]
(17911)

q1
q2
q3
q4
q5
q6
q7
Q.323

Same fuel type used as originally designed
gasoline
propane
natural gas
diesel
kerosene
don't know / refuse

What was the brand of generator?
INTERVIEWER: Read list.

[REQUIRE ANSWER]
(17912)

q1
q2
q3
q4
q5
q6
q7

Coleman
Generac
Honda
Sears/Craftsman
Troy-Bilt
other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 323 IS NOT 6, THEN SKIP TO QUESTION 325]

Q.324

What brand name is listed on the generator?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.325

Do you know the model of the generator?
[REQUIRE ANSWER]
(17943)

q 1 Yes
q 2 No
q 3 Don't Know / Refuse
[A - IF THE ANSWER TO QUESTION 325 IS NOT 1, THEN SKIP TO QUESTION 327]

OMB Control Number 3041-0029

(17913-17942)

Q.326

What is the generator model?
[REQUIRE ANSWER]
__________________________________________________________________________

(17944-17973)

[A - IF THE ANSWER TO QUESTION 325 IS 1, THEN SKIP TO QUESTION 330]

Q.327

What are the approximate dimensions of the generator in inches?
INTERVIEWER: List as Length by Width by Height separated by "x", for example, 30x18x20. Enter
"999" for unknown.
[REQUIRE ANSWER]
__________________________________________________________________________

[A - IF THE ANSWER TO QUESTION 315 IS 2, THEN SKIP TO QUESTION 330]

Q.328

Can it be hand carried by one person?
[REQUIRE ANSWER]
(17989)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.329

Does it have two or more wheels for transporting it?
[REQUIRE ANSWER]
(17990)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.330

Could you tell me what the wattage output rating of the generator is?
INTERVIEWER: Please enter "999" for "Don't know" or refusal.
[REQUIRE ANSWER]
__________ (17991-17995)
[A - IF THE ANSWER TO QUESTION 330 IS 999, THEN SKIP TO QUESTION 333]

OMB Control Number 3041-0029

(17974-17988)

Q.331

How was this wattage output rating specified as? Was this "run watts", "continuous watts",
"surge watts", "starting watts" or "maximum watts"?
[REQUIRE ANSWER]
(17996)

q1
q2
q3
q4
q5
q6
q7

run watts
continuous watts
surge watts
starting watts
maximum watts
other
don't know / refuse
[A - IF THE ANSWER TO QUESTION 331 IS NOT 6, THEN SKIP TO QUESTION 333]

Q.332

How was the wattage rating defined?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.333

(17997-18046)

Could you tell me what the engine horsepower rating is?
INTERVIEWER: Please enter "999" for "Don't know" or refusal.
[REQUIRE ANSWER]
__________ (18047-18051)

Q.334

I will give you a list of choices, please pick the one that best describes how you/the user
obtained the generator:
INTERVIEWER: Read list.
[REQUIRE ANSWER]
(18052)

q1
q2
q3
q4
q5
q6
q7

purchased - new
purchased - previously owned
rented
borrowed
FEMA supplied
other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 334 IS NOT 6, THEN SKIP TO QUESTION 336]

OMB Control Number 3041-0029

Q.335

How was the generator obtained?
[REQUIRE ANSWER]
__________________________________________________________________________

(18053-18152)

[A - IF THE ANSWER TO QUESTION 334 IS 4 OR 5 OR 6 OR 7, THEN SKIP TO QUESTION 337]

Q.336

What is the name of the retailer / rental company from which you obtained the generator?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.337

(18153-18252)

When was the generator first obtained?
INTERVIEWER: If the respondent gives a specific date, use MM/DD/YY format. Otherwise, enter
whatever they provide (e.g. "Last summer", "Last June", etc.) Enter
"unknown" if date unknown or
refusal.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.338

Had the generator been working properly before this incident?
[REQUIRE ANSWER]
(18353)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 338 IS NOT 2, THEN SKIP TO QUESTION 340]

OMB Control Number 3041-0029

(18253-18352)

Q.339

What types of problems did the generator have?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.340

(18354-18503)

Had the product been modified or repaired prior to the incident?
[REQUIRE ANSWER]
(18504)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 340 IS NOT 1, THEN SKIP TO QUESTION 342]

Q.341

Could you please explain what had been done to repair or modify the product and by whom
and why?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.342

Did you or the primary user receive an owner’s manual with the generator?
[REQUIRE ANSWER]
(18655)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 342 IS NOT 1, THEN SKIP TO QUESTION 344]

Q.343

Do you or the user still have the manual?
[REQUIRE ANSWER]
(18656)

q 1 Yes
q 2 No
q 3 Don't know / Refuse

OMB Control Number 3041-0029

(18505-18654)

Q.344

Prior to use, did any user or victim see the owner's manual or see the manufacturer’s hazard
warnings on the generator regarding the possibility of injury?
[REQUIRE ANSWER]
(18657)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.345

When you or the user obtained the generator, did any other safety information on potential
generator hazards come with it?
[REQUIRE ANSWER]
(18658)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.346

When you or the user obtained the generator, do you recall seeing or hearing any advice on
the need or benefit of getting and using a CO alarm when operating the generator?
[REQUIRE ANSWER]
(18659)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.347

At the time of the incident, was a CO alarm in use?
[REQUIRE ANSWER]
(18660)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 347 IS NOT 1, THEN SKIP TO QUESTION 350]

OMB Control Number 3041-0029

Q.348

Where was the CO alarm in relation to the generator and the victim?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.349

(18661-18860)

Did the CO alarm give a warning?
[REQUIRE ANSWER]
(18861)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
Q.350

Had you or the user ever used the generator prior to this incident and, if so, how often?
INTERVIEWER: Select the choice from the list that best fits the respondents reply.

[REQUIRE ANSWER]
(18862)

q1
q2
q3
q4
q5

No, this was the first time
Yes, once before
Yes, but not recently
Yes, quite often
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 350 IS 1 OR 6, THEN SKIP TO QUESTION 352]

Q.351

When was the last time that the generator was used prior to this incident?
INTERVIEWER: If the respondent gives a specific date, use MM/DD/YY format. Otherwise, enter
whatever they provide (e.g. "Last summer", "Last June", etc.) Enter
"unknown" if date is not known or
refusal.
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(18863-18892)

Q.352

What level of experience did you or the user have in operating generators in general?
INTERVIEWER: Please select the response that best fits the respondents reply.
[REQUIRE ANSWER]
(18893)

q1
q2
q3
q4
q5
q6
Q.353

Never used one before
Have used one once before
Occasionally used one, but not recently
Occasionally use one
Use one regularly
Don't know / Refuse

At what time of day did this incident occur?
If the respondent provides a time, use the HH:MM am/pm format. Otherwise, enter what the respondent
replies.
(e.g. "In the evening", "Around noon", etc.)
[REQUIRE ANSWER]
__________________________________________________________________________

Q.354

How were appliances connected to the generator for use?
INTERVIEWER: Select the choice that best fits the respondent's answer.
[REQUIRE ANSWER]
(18944)

q1
q2
q3
q4
q5
q6
q7

items were plugged directly into the generator's outlet sockets
items were connected via extension cords
professionally-installed transfer switch to power the whole home
homeowner-installed transfer switch to power the whole home
generator was plugged directly into a wall outlet to power the whole home
other
Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 354 IS NOT 6, THEN SKIP TO QUESTION 356]

OMB Control Number 3041-0029

(18894-18943)

Q.355

Could you please describe how the appliances were connected to the generator?
[REQUIRE ANSWER]
__________________________________________________________________________

(18945-19044)

[A - IF THE ANSWER TO QUESTION 354 IS NOT 1 OR 2, THEN SKIP TO QUESTION 359]

Q.356

How were the extension cords or the appliance cords run to the generator? From the
following list, please choose the answer that best fits the situation.
INTERVIEWER: Please read list to respondent.
[REQUIRE ANSWER]
(19045)

q1
q2
q3
q4
q5
q6
q7

Appliance was in the same room as the generator
Cords were run through an open window
Cords were run through a window just open enough to allow the cord through
Cords were run through an open doorway
Cords were run through a doorway just open enough to allow the cord through
Cords were run through a hole in the wall
Other
[A - IF THE ANSWER TO QUESTION 356 IS NOT 7, THEN SKIP TO QUESTION 359]

Q.357

Could you please give me some details?
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(19046-19245)

Q.358

Could you describe any other way that you or someone else tried to isolate or seal off the
generator from location of the victims.
INTERVIEWER: Enter N
" one" if no attempt was made to isolate the generator. EnterDon't
"
know" if the
respondent doesn't know or R
" efuse" if they refuse to answer the question.
[REQUIRE ANSWER]
__________________________________________________________________________

Q.359

Prior to this incident, did you or the primary user know of any hazards associated with
portable generators?
[REQUIRE ANSWER]
(19446)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 359 IS NOT 1, THEN SKIP TO QUESTION 362]

Q.360

(19246-19445)

What hazards were known by the user prior to use?
[REQUIRE ANSWER]
(19447-19450)

q1
q2
q3
q4
q5

electrocution or shock
carbon monoxide poisoning
fire
contact burn
Don't know / Refuse

OMB Control Number 3041-0029

Q.361

How did the user learn of these hazards?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.362

(19451-19600)

When the victim(s) were found, was the generator engine still running?
[REQUIRE ANSWER]
(19601)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 362 IS 1, THEN SKIP TO QUESTION 364]

Q.363

Was the generator switch in the ON or OFF position?
[REQUIRE ANSWER]
(19602)

q 1 On
q 2 Off
q 3 Don't know / Refuse
Q.364

When the victim(s) were found, how much fuel was in the generator's tank?
[REQUIRE ANSWER]
(19603)

q1
q2
q3
q4
Q.365

empty
partially full
full
Don't know / Refuse

How many times had the generator’s fuel tank been refilled during this incident (not including
the initial fill up)?
INTERVIEWER: If the generator was in continuous use (for example, if the generator was the regular
If unknown enter 99".
"
source of power to the home/structure) enter88".
"
[REQUIRE ANSWER]
____ (19604-19605)

OMB Control Number 3041-0029

Q.366

At the time of the incident was the victim interacting with the generator (For example, was the
victim refilling the tank?)
[REQUIRE ANSWER]
(19606)

q 1 Yes
q 2 No
q 3 Don't know / Refuse
[A - IF THE ANSWER TO QUESTION 366 IS NOT 1, THEN SKIP TO QUESTION 368]

Q.367

What was the victim doing?
[REQUIRE ANSWER]
__________________________________________________________________________

Q.368

(19607-19756)

This concludes the survey. I thank you very much for your cooperation and your time in this
effort to prevent generator related injuries in the future.
If I missed anything, may I call you back?
INTERVIEWER: Terminate call after entering answer. Enter date this interview was completed on next
screen.
[REQUIRE ANSWER]
(19757)

q 1 Yes
q 2 No
[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 370]
[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 370]

Q.369

Thank you for your time.
INTERVIEWER: Terminate call. Enter date this interview was completed on next screen.

Q.370

INTERVIEWER: What is the date this interview was completed? (MM/DD/YY)
[REQUIRE ANSWER]
__________________________________________________________________________

OMB Control Number 3041-0029

(19758-19767)

OMB Control Number 3041-0029