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pdfSubmersion Incidents Children Under 5
Questionnaire # ________ (1-4)
Q.1 Please enter Task Number
_________________________________________________________________________________
(5-17)
Q.2 Hello, may I speak with the parent or guardian of __________?
I'm calling for the Consumer Product Safety Commission. I understand that (Victim's Name) had a
submersion or drowning accident. We are presently performing a study on childhood submersions and
near drownings and would like to ask you some questions about the accident.
Be prepared to answer questions with the following information:
- that the identity will be kept confidential
- that the purpose of the study is to prevent future incidents and injuries
- there is a particular interest in the circumstances surrounding the childhood submersion or near
drowning
(18)
q1
q2
Agreed
Refused
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 175]
Q.3 Are you familiar with how this incident happened?
(19)
q1
q2
Yes
No
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 8]
Q.4 Is there someone else who is more familiar with the details of the incident?
(20)
q1
q2
Yes
No
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 175]
Q.5 May I speak with him/her?
(21)
q1
q2
Yes
No
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 2]
Q.6 Record name and phone number if different
________________________________________________________________________________
OMB Control Number 3041-0029
(22-71)
Q.7 When would be a good time to contact him/her?
________________________________________________________________________________
(72-96)
[IF THE ANSWER TO QUESTION 5 IS 2, THEN SKIP TO QUESTION 175]
Q.8 I understand that (Victim's Name) was treated at the emergency room on (date) following a submersion
or near drowning accident. Is that correct?
(97)
q1
q2
Yes
No
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 11]
-2-
OMB Control Number 3041-0029
Q.9 Please give a brief summary of the reason for the emergency room visit.
_______________________________________________________________________________
(98-597)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Q.10 If the incident did not involve a submersion incident, end the interview.
(598)
q1
q2
End the interview
Continue
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 174]
Q.11 What was the child doing prior to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
-3-
OMB Control Number 3041-0029
(599-848)
Q.12 Where was the child before the incident?
_____________________________________________________________________________
(849-1098)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Q.13 How did the child get to the water source?
____________________________________________________________________________
(1099-1348)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Q.14 How was the child found?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
-4-
OMB Control Number 3041-0029
(1349-1598)
Q.15 What happened after the child was found?
____________________________________________________________________________
(1599-1848)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Q.16 Were any other children involved in the incident?
(1849)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 18]
Q.17 What relationship were the other children to (name of victim) ?
Interviewer: Probe for ages of other children.
____________________________________________________________________________
(1850-1949)
____________________________________________________________________________
Q.18 What day of the week and time did the incident occur?
____________________________________________________________________________
____________________________________________________________________________
-5-
OMB Control Number 3041-0029
(1950-2049)
Q.19 Is there anything else about the incident that the CPSC should know about?
____________________________________________________________________________
(2050-2299)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Given the the description you just gave me, some of the following questions may seem
repetitive and I apologize for that. We're just trying to answer some important questions to
improve product safety and your help with these questions will be greatly appreciated.
Please read responses to questions to allow respondent to hear all possible answers. Please DO NOT read
the Don't Know responses. Use this only if offered by the respondent.
Q.20 I'm going to read a list of products, please indicate the product that was involved in the accident. Was it
a:
(2300)
q1
q2
q3
q4
q5
q6
q7
Swimming pool (includes all types of pools)
Bucket
Spa or hot tub
Bathtub (includes baby bathtubs & bathinettes)
Toilet
Pond
Other
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 23]
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 90]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 100]
[IF THE ANSWER IS 4, THEN SKIP TO QUESTION 113]
[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 130]
[IF THE ANSWER IS 6, THEN SKIP TO QUESTION 136]
-6-
OMB Control Number 3041-0029
Q.21 Please describe the Other product involved.
____________________________________________________________________________
(2301-2400)
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 21 IS 7, THEN SKIP TO QUESTION 147]
Q.22 What type of swimming pool was involved?
(2401)
q1
q2
q3
q4
q5
In-ground pool
Above-ground pool
On-ground pool
Inflatable pool
Wading pool
Q.23 Where is the location of the pool?
(2402)
q1
q2
q3
q4
Own residence
Other person's residence
Recreational or public area
Other
[IF THE ANSWER IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 26]
Q.24 Please describe the Other location of the pool.
____________________________________________________________________________
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 23 IS 5, THEN SKIP TO QUESTION 75]
[IF THE ANSWER TO QUESTION 23 IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 54]
[IF THE ANSWER TO QUESTION 24 IS 1 OR 2, THEN SKIP TO QUESTION 27]
Q.25 Was a lifeguard on duty at the pool?
(2503)
q1
q2
q3
Yes
No
Don't know
-7-
OMB Control Number 3041-0029
(2403-2502)
Q.26 Did (Victim's Name) have permission to be in the area of the pool?
(2504)
q1
q2
q3
Yes
No
Don't know
Q.27 Was the child using any type of swimming product, for instance water wings, noodles, inner tubes?
(2505)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 30]
Q.28 Please describe the type of swimming product the child was using.
____________________________________________________________________________
(2506-2605)
____________________________________________________________________________
Q.29 Were you able to see the bottom of the pool on the day of the accident?
(2606)
q1
q2
q3
Yes
No
Don't know
Q.30 Prior to the accident, had the child ever had any type of formal water instruction? This could include
water familiarity classes, water safety, beginner swimming lessons or other types of lessons?
(2607)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 33]
-8-
OMB Control Number 3041-0029
Q.31 Please describe the type of water instruction the child had received including where the classes were
taken, the nature of the skills taught and the approximate number of classes taken.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Q.32 Was the pool an indoor pool or an outdoor pool?
(3108)
q1
q2
Indoor Pool
Outdoor Pool
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 41]
Q.33 How did (Victim's Name) get into the area of the indoor pool?
(3109)
q1
q2
q3
q4
q5
q6
Open door
Cosed door
Open gate
Closed gate
Don't know
Other
[IF THE ANSWER IS 1 OR 3 OR 5, THEN SKIP TO QUESTION 39]
[IF THE ANSWER IS 2 OR 4, THEN SKIP TO QUESTION 36]
-9-
OMB Control Number 3041-0029
(2608-3107)
Q.34 Please describe how (Victim's Name) got into the area of the indoor pool.
____________________________________________________________________________
(3110-3409)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Q.35 Was there an alarm on the closed door/gate?
(3410)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 39]
Q.36 Please describe the alarm on the door/gate.
____________________________________________________________________________
____________________________________________________________________________
Q.37 Was the alarm on the door/gate activated and working at the time of the accident?
(3511)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated but not working
Neither working or activated
Don't know
Q.38 Was there an alarm on the pool to alert when the water was disturbed?
(3512)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
OMB Control Number 3041-0029
(3411-3510)
-10-
OMB Control Number 3041-0029
Q.39 Was the alarm on the pool working and activated at the time of the accident?
(3513)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated but not working
Neither working or activated
Don't know
[IF THE ANSWER TO QUESTION 33 IS 1, THEN SKIP TO QUESTION 147]
[IF THE ANSWER TO QUESTION 24 IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 43]
Q.40 How old is the pool, in years?
____________________________________________________________________________
Q.41 How long have you lived in this home with the pool in the yard, in years please?
________ (3524-3527)
Q.42 What was (Victim's Name) doing before the accident?
(3528)
q1
q2
q3
q4
Activity in the house
Activity in the yard
Activity near the pool
Playing in the pool
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 48]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 53]
[IF THE ANSWER IS 4, THEN SKIP TO QUESTION 147]
Q.43 How did the child gain access to the yard?
(3529)
q1
q2
q3
q4
q5
Open door
Closed door
Open window
Closed window
Don't know
[IF THE ANSWER IS 1 OR 3 OR 5, THEN SKIP TO QUESTION 48]
-11-
OMB Control Number 3041-0029
(3514-3523)
Q.44 Was there an alarm on the door or window to alert the homeowner that the door/window had been
opened?
(3530)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 48]
Q.45 Please describe the alarm on the door or window.
____________________________________________________________________________
(3531-3630)
____________________________________________________________________________
Q.46 Was the alarm on the door/window activated and working at the time of the accident?
(3631)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated but not working
Neither working or activated
Don't know
Q.47 This next question is about the type of barrier around the pool and where the child was with respect to
the barrier. Please listen to all the options before replying.
(3632)
q1
q2
q3
q4
Was the child outside of the fence for the pool but still in the yard?
Was the child already within the fence for the pool once through the door/window?
There was no fence for the pool or the yard
Don't know
[IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 53]
Q.48 Approximately how tall was the fence around just the pool, in feet?
________ (3633-3636)
Q.49 Was the gate to the fence open or closed?
(3637)
q1
q2
Open gate
Closed gate
OMB Control Number 3041-0029
-12-
OMB Control Number 3041-0029
q3
Don't know
[IF THE ANSWER IS 1 OR 3, THEN SKIP TO QUESTION 53]
Q.50 Was the closed gate locked or unlocked?
(3638)
q1
q2
q3
Locked
Unlocked
Don't know
Q.51 Was the gate a self-latching gate or a self-closing gate?
(3639)
q1
q2
q3
Yes
No
Don't know
Q.52 Did the pool have an alarm on it to alert when the water was disturbed?
(3640)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 147]
Q.53 What was (Victim's Name) doing just before the accident?
(3641)
q1
q2
q3
q4
Activity in the house
Activity in the yard
Playing on the decking near the pool
Playing in the pool
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 59]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 67]
[IF THE ANSWER IS 4, THEN SKIP TO QUESTION 70]
Q.54 How did the child get outside to the yard?
(3642)
q1
q2
q3
q4
q5
Open door
Closed door
Open window
Closed window
Don't know
[IF THE ANSWER IS 1 OR 3 OR 5, THEN SKIP TO QUESTION 59]
-13-
OMB Control Number 3041-0029
Q.55 Was there an alarm on the door or window to alert the homeowner that the door or window had been
opened?
(3643)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 59]
Q.56 Please describe the alarm on the door/window.
____________________________________________________________________________
(3644-3743)
____________________________________________________________________________
Q.57 Was the alarm or the door/window activated and working at the time of the accident?
(3744)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated by not working
Neither working or activated
Don't know
Q.58 Did the swimming pool have any type of fencing or enclosure around it?
(3745)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 62]
Q.59 Please describe the type of enclosure or fencing around the pool.
____________________________________________________________________________
____________________________________________________________________________
Q.60 Approximately how tall was the fence or enclosure, in feet?
________ (3846-3849)
OMB Control Number 3041-0029
(3746-3845)
-14-
OMB Control Number 3041-0029
Q.61 What is the normal mode of entry to the swimming pool?
(3850)
q1
q2
q3
q4
q5
Ladder
Steps
Deck
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 64]
[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 67]
Q.62 Please describe the type of entry to the pool.
____________________________________________________________________________
(3851-3950)
____________________________________________________________________________
Q.63 Could this entryway be removed when the pool was not in use?
(3951)
q1
q2
q3
Yes
No
Don't know
Q.64 Was there any way to block the entrance to the pool so that the child could not access it?
(3952)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 67]
Q.65 Please describe how the entrance could be blocked.
____________________________________________________________________________
____________________________________________________________________________
-15-
OMB Control Number 3041-0029
(3953-4052)
Q.66 Was there any type of alarm on the pool to notify when a child had fallen or jumped into the pool?
(4053)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 70]
Q.67 Please describe the alarm on the pool.
____________________________________________________________________________
(4054-4153)
____________________________________________________________________________
Q.68 Was the alarm on the pool activated and working at the time of the accident?
(4154)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated but not working
Neither working or activated
Don't know
Q.69 Was the child using any type of swimming product, for instance water wings, noodles, inner tubes?
(4155)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 72]
Q.70 Please describe the type of swimming product that the child was using at the time of the accident.
____________________________________________________________________________
____________________________________________________________________________
Q.71 Were you able to see the bottom of the pool on the day of the accident?
(4256)
OMB Control Number 3041-0029
(4156-4255)
-16-
OMB Control Number 3041-0029
q1
q2
q3
Yes
No
Don't know
Q.72 Prior to the accident, had the child ever had any type of formal water instruction? This could include
water familiarity classes, beginner swimming lessons, deep water instruction, or water safety.
(4257)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
-17-
OMB Control Number 3041-0029
Q.73 Please describe the type of water instruction the child had received including where the classes were
taken, the nature of skills taught and the approximate number of classes taken.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 73 IS 1, THEN SKIP TO QUESTION 147]
Q.74 Was the wading pool intentionally filled with water by a caregiver?
(4758)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1 OR 3, THEN SKIP TO QUESTION 78]
Q.75 How did water get into the wading pool?
(4759)
q1
q2
q3
q4
Rainfall
Child filled the wading pool
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 4, THEN SKIP TO QUESTION 78]
-18-
OMB Control Number 3041-0029
(4258-4757)
Q.76 Please describe how the wading pool became full of water.
____________________________________________________________________________
(4760-4859)
____________________________________________________________________________
Q.77 How long had the water been in the wading pool?
____________________________________________________________________________
(4860-4959)
____________________________________________________________________________
Q.78 What was the child doing before the accident?
(4960)
q1
q2
q3
Activity inside the home
Activity outside the home
Playing in the wading pool
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 85]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 88]
Q.79 How did the child gain access to the yard?
(4961)
q1
q2
q3
q4
q5
Open door
Closed door
Open window
Closed window
Don't know
[IF THE ANSWER IS 1 OR 3 OR 5, THEN SKIP TO QUESTION 85]
Q.80 Was the door/window locked before the child exited the home?
(4962)
q1
q2
q3
Yes
No
Don't know
Q.81 Was there an alarm on the door or window to alert the homeowner that the door/window had been
opened?
(4963)
OMB Control Number 3041-0029
-19-
OMB Control Number 3041-0029
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 85]
Q.82 Please describe the alarm on the door/window.
____________________________________________________________________________
(4964-5063)
____________________________________________________________________________
Q.83 Was the alarm on the door/window activated and working at the time of the accident?
(5064)
q1
q2
q3
q4
q5
Working and activated
Working but not activated
Activated but not working
Neither working or activated
Don't know
Q.84 Were there any barriers around the wading pool to prevent the child from entering the water?
(5065)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 88]
Q.85 Please describe the type of barrier in place.
____________________________________________________________________________
____________________________________________________________________________
-20-
OMB Control Number 3041-0029
(5066-5165)
Q.86 Please describe how the child overcame the barrier to get access to the wading pool.
____________________________________________________________________________
(5166-5265)
____________________________________________________________________________
Q.87 Prior to the accident, had the child ever had any type of formal water instruction? This could include
water familiarity classes, beginner swimming lessons, deep water instruction or water safety.
(5266)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
-21-
OMB Control Number 3041-0029
Q.88 Please describe the type of water instruction the child received including where the classes were taken,
the nature of skills taught and the approximate number of classes taken.
____________________________________________________________________________
(5267-5766)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 88 IS 1, THEN SKIP TO QUESTION 147]
Q.89 Of the following shapes, please select the shape that describes the top of the bucket.
(5767)
q1
q2
q3
q4
q5
Circle
Square
Rectangle
Oval
Don't know
Q.90 Can you recall the amount of liquid that the bucket can hold total?
We're looking for answers like 5 gallons, 4 quarts, etc.
____________________________________________________________________________
____________________________________________________________________________
-22-
OMB Control Number 3041-0029
(5768-5867)
Q.91 What was the bucket being used for at the time of the accident?
(5868)
q1
q2
q3
q4
q5
q6
Cleaning
Storage
Laundry
Water supply
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6, THEN SKIP TO QUESTION 94]
Q.92 Please describe what the bucket was being used for before the accident.
____________________________________________________________________________
(5869-5968)
____________________________________________________________________________
Q.93 Please describe the contents of the bucket at the time of the accident.
____________________________________________________________________________
(5969-6068)
____________________________________________________________________________
Q.94 What room was the bucket in?
No need to read the responses unless the respondent doesn't know or hesitates.
(6069)
q1
q2
q3
q4
q5
q6
q7
q8
q9
Kitchen
Bathroom
Hallway
Bedroom
Utility room
Garage
Outside
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 9, THEN SKIP TO QUESTION 97]
Q.95 Please specify the Other room that the bucket was located in at the time of the accident.
____________________________________________________________________________
OMB Control Number 3041-0029
(6070-6119)
-23-
OMB Control Number 3041-0029
Q.96 How long had the liquid been in the bucket prior to the accident?
____________________________________________________________________________
(6120-6219)
____________________________________________________________________________
Q.97 When (Victim's Name) fell into the bucket, did the bucket tip over or stay upright?
(6220)
q1
q2
q3
q4
Tipped over
Stayed upright
Neither
Don't know
[IF THE ANSWER IS 1 OR 2 OR 4, THEN SKIP TO QUESTION 147]
Q.98 Please describe what happened to the bucket when the child fell into the bucket.
____________________________________________________________________________
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 98 IS 3, THEN SKIP TO QUESTION 147]
Q.99 Where was the spa/hot tub located?
(6321)
q1
q2
q3
q4
Own residence
Other's residence
Recreational area/public area/hotel/motel/other
Don't know
[IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 102]
Q.100 Was there a lifeguard supervising the hot tub at the time of the accident?
(6322)
q1
q2
q3
Yes
No
Don't know
-24-
OMB Control Number 3041-0029
(6221-6320)
Q.101 This next question is a bit more specific about the location of the hot tub. Please choose which best
describes the specific location of the hot tub. Was the hot tub...
(6323)
q1
q2
q3
q4
q5
Indoors
Outdoors
In a covered porch area
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3 OR 5, THEN SKIP TO QUESTION 104]
Q.102 Please describe the Other location of the hot tub.
____________________________________________________________________________
(6324-6423)
____________________________________________________________________________
Q.103 Was the hot tub in-ground or above-ground?
(6424)
q1
q2
q3
In-ground
Above-ground
Don't know
Q.104 Was there any type of barrier around the hot tub, like a fence or a door to prevent access to the hot tub?
(6425)
q1
q2
q3
q4
q5
Fence
Door
None
Other
Don't know
[IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 107]
[IF THE ANSWER IS 3 OR 5, THEN SKIP TO QUESTION 111]
Q.105 Please describe the Other type of barrier around the hot tub.
____________________________________________________________________________
____________________________________________________________________________
OMB Control Number 3041-0029
(6426-6525)
-25-
OMB Control Number 3041-0029
Q.106 Was the barrier open or closed before the child gained access to the hot tub?
(6526)
q1
q2
q3
Open
Closed
Don't know
[IF THE ANSWER IS 1 OR 3, THEN SKIP TO QUESTION 111]
Q.107 Was there any type of alarm or lock on the barrier to alert/stop entry into the hot tub?
(6527)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 111]
Q.108 Please describe the alarm or lock on the barrier to the hot tub.
____________________________________________________________________________
____________________________________________________________________________
Q.109 Was the alarm or lock on the barrier to the hot tub working at the time of the incident?
(6628)
q1
q2
q3
Yes
No
Don't know
Q.110 Did the child have permission to be in the area of the hot tub?
(6629)
q1
q2
q3
Yes
No
Don't know
Q.111 Was there a cover on the hot tub at the time of the accident?
(6630)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 147]
OMB Control Number 3041-0029
(6528-6627)
-26-
OMB Control Number 3041-0029
Q.112 Did (Victim's Name) fall into the bathtub, climb into the bathtub, or was (Victim's Name)
in the bathtub by a caregiver?
placed
(6631)
q1
q2
q3
q4
Fell into the bathtub
Climbed into the bathtub
Placed into the bathtub
Don't know
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 119]
Q.113 Was there standing water in the bathtub at the time or did (Victim's Name) fill the bathtub with
water?
(6632)
q1
q2
q3
q4
Standing water in the tub
Victim filled the tub
Other
Don't know
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 116]
[IF THE ANSWER IS 2 OR 4, THEN SKIP TO QUESTION 117]
Q.114 Please describe how the water got into the bathtub.
____________________________________________________________________________
(6633-6732)
____________________________________________________________________________
Q.115 How long before the accident had the water been in the bathtub?
____________________________________________________________________________
____________________________________________________________________________
Q.116 Were other children involved in the accident?
(6833)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
-27-
OMB Control Number 3041-0029
(6733-6832)
Q.117 Please describe how the other children were involved in the accident.
Interviewer: Probe for ages of other children.
____________________________________________________________________________
(6834-6933)
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 117 IS 1, THEN SKIP TO QUESTION 147]
Q.118 Approximately how deep was the water at the time of the accident, in inches please?
________ (6934-6937)
Q.119 Was the water left running at the time of the accident?
(6938)
q1
q2
q3
Yes
No
Don't know
Q.120 Was the drain open or closed at the time of the accident?
(6939)
q1
q2
q3
Open
Closed
Don't know
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 124]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 125]
Q.121 Had anything blocked the drain or was the water draining as intended?
(6940)
q1
q2
q3
Blocked drain
Draining as intended
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 125]
Q.122 What was blocking the drain?
____________________________________________________________________________
[IF THE ANSWER TO QUESTION 122 IS 1, THEN SKIP TO QUESTION 125]
OMB Control Number 3041-0029
(6941-6990)
-28-
OMB Control Number 3041-0029
Q.123 What was used to plug the drain?
____________________________________________________________________________
(6991-7040)
Q.124 Was the child using any type of bathing aid at the time of the accident?
(7041)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 128]
Q.125 Was the product a:
(7042)
q1
q2
q3
q4
q5
Bathinette
Bath seat
Baby bath tub
Inflatable support
Other
[IF THE ANSWER IS 1 OR 2 OR 3 OR 4, THEN SKIP TO QUESTION 128]
Q.126 What was the Other product that the child was using at the time of the accident?
____________________________________________________________________________
____________________________________________________________________________
Q.127 Were any other children involved in the accident?
(7143)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 130]
-29-
OMB Control Number 3041-0029
(7043-7142)
Q.128 Please describe how the other children were involved in the accident.
Interviewer: Probe for ages of other children.
____________________________________________________________________________
____________________________________________________________________________
Q.129 Prior to the accident, had the door of the bathroom been open or closed?
(7244)
q1
q2
q3
q4
Open
Closed
Don't know
Did not occur in bathroom
[IF THE ANSWER TO QUESTION 128 IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 147]
Q.130 Usually, is the toilet lid left open or closed?
(7245)
q1
q2
q3
Open
Closed
Don't know
Q.131 On this particular occasion, was the toilet lid left open or closed?
(7246)
q1
q2
q3
Open
Closed
Don't know
Q.132 Was there a toilet lock on the toilet?
(7247)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
Q.133 Was the toilet locked in place at the time of the accident?
(7248)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
OMB Control Number 3041-0029
(7144-7243)
-30-
OMB Control Number 3041-0029
Q.134 Had the child previously defeated the toilet lock?
(7249)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3, THEN SKIP TO QUESTION 147]
Q.135 Was the pond a man-made pond with a liner?
(7250)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 139]
Q.136 Was this a natural pond?
(7251)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 139]
Q.137 Please describe the type of pond involved in the accident.
____________________________________________________________________________
____________________________________________________________________________
Q.138 Before the accident occurred, was the child taking part in:
(7352)
q1
q2
q3
An activity inside the house
An activity outside of the house
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 144]
-31-
OMB Control Number 3041-0029
(7252-7351)
Q.139 How did the child gain access to the area near the pond?
(7353)
q1
q2
q3
q4
q5
q6
Open door
Closed door
Open window
Closed window
Don't know
Other
[IF THE ANSWER IS 1 OR 3 OR 5 OR 6, THEN SKIP TO QUESTION 144]
Q.140 Was there an alarm or lock on the door or window to alert the homeowner that the door/window had
been opened?
(7354)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 144]
Q.141 Please describe the alarm or lock on the door/window.
____________________________________________________________________________
____________________________________________________________________________
Q.142 Was the alarm or lock on the door/window working at the time of the incident?
(7455)
q1
q2
q3
Yes
No
Don't know
Q.143 Was there any type of barrier around the pond to prevent access to the pond?
(7456)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 147]
-32-
OMB Control Number 3041-0029
(7355-7454)
Q.144 Please describe the type of barrier around the pond.
____________________________________________________________________________
(7457-7556)
____________________________________________________________________________
Q.145 How did the child get past the barrier?
____________________________________________________________________________
(7557-7656)
____________________________________________________________________________
Q.146 I'm now going to ask some information about (Victim's Name) .
What was
(Victim's Name) 's age at the time of the accident?
(7657)
q1
q2
q3
q4
1 month to 23 months old
2 years old to 35 months old
3 years old to 47 months old
4 years old or older
[IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 154]
Q.147 I'm going to list some developmental milestones for children under 2 years old. Please answer yes or
no as to whether (Victim's Name) was able to do this task at the time of the accident.
Roll over?
(7658)
q1
q2
q3
Yes
No
Don't know
Q.148 Sit up?
(7659)
q1
q2
q3
Yes
No
Don't know
Q.149 Pull up to a stand?
(7660)
OMB Control Number 3041-0029
-33-
OMB Control Number 3041-0029
q1
q2
q3
Yes
No
Don't know
Q.150 Stand alone?
(7661)
q1
q2
q3
Yes
No
Don't know
Q.151 Crawl?
(7662)
q1
q2
q3
Yes
No
Don't know
Q.152 Walk?
(7663)
q1
q2
q3
Yes
No
Don't know
Q.153 Can you please tell me (Victim's Name) 's height at the time of the accident? Specify units of
measurement
____________________________________________________________________________
(7664-7763)
____________________________________________________________________________
Q.154 Can you please tell me (Victim's Name) 's weight at the time of the accident? Specify the units of
measurement
____________________________________________________________________________
(7764-7813)
Q.155 Did the victim have any physical or mental disabilities that may have contributed to the accident?
(7814)
q1
q2
Yes
No
OMB Control Number 3041-0029
-34-
OMB Control Number 3041-0029
q3
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 158]
Q.156 Please describe the disability that may have contributed to the accident.
____________________________________________________________________________
(7815-7914)
____________________________________________________________________________
Q.157 At the time of the accident, was (Victim's Name)
from someone else or a flotation aid?
able to keep his/her head above water without help
(7915)
q1
q2
q3
Yes
No
Don't know
Q.158 What was (Victim's Name) wearing at the time of the accident (waterwings, flotation devices,
swimsuit, clothes, etc.)?
____________________________________________________________________________
(7916-8015)
____________________________________________________________________________
Q.159 I just have a few more questions. I'd like to ask about what happened after the child became
submerged in the water. Did a caregiver bring (Victim's Name) to the emergency room or was an
ambulance called to transport (Victim's Name) ?
(8016)
q1
q2
q3
q4
Brought by caregiver to ER
Brought by ambulance to ER
Other
Don't know
[IF THE ANSWER IS 1 OR 2 OR 4, THEN SKIP TO QUESTION 162]
-35-
OMB Control Number 3041-0029
Q.160 Please specify the other way (Victim's Name) was brought to the emergency room.
____________________________________________________________________________
(8017-8116)
____________________________________________________________________________
Q.161 Was CPR attempted following the accident?
(8117)
q1
q2
q3
Yes
No
Don't know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 164]
Q.162 Who performed CPR on (Victim's Name) ?
____________________________________________________________________________
(8118-8167)
Q.163 Do you recall how much time passed from when the child was found and when the child received
professional medical attention? Specify units of measurement
____________________________________________________________________________
(8168-8267)
____________________________________________________________________________
Q.164 Who was the professional medical person that gave attention?
____________________________________________________________________________
____________________________________________________________________________
Q.165 Is (Victim's Name) still under medical care due to the accident?
(8368)
q1
Yes
OMB Control Number 3041-0029
(8268-8367)
-36-
OMB Control Number 3041-0029
q2
q3
No
Don't know
[IF THE ANSWER IS 1 OR 3, THEN SKIP TO QUESTION 168]
Q.166 How long was (Victim's Name) under medical care after the accident?
____________________________________________________________________________
Q.167 What is the long term medical outlook for
(8369-8418)
(Victim's Name) ?
____________________________________________________________________________
(8419-8618)
____________________________________________________________________________
____________________________________________________________________________
Q.168 Who was supervising (Victim's Name) at the time of the accident?
(8619)
q1
q2
q3
q4
Family member
Friend
Baby sitter
Other
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 171]
Q.169 Please describe the relationship of the caregiver and (Victim's Name) .
____________________________________________________________________________
____________________________________________________________________________
Q.170 Can you tell me the approximate age of the caregiver?
________ (8720-8723)
-37-
OMB Control Number 3041-0029
(8620-8719)
Q.171 READ WITH GREAT SENSITIVITY!!!
The way caregivers supervise children varies by the situation and the activity of the child as well as the
child's age. I have some different forms of supervision that I will read to you. Please indicate the type of
supervision of (Victim's Name) at the time of the accident. Was the caregiver:
(8724)
q1
q2
q3
q4
q5
q6
Within arm's reach of the child
Directly watching the child, but not necessarily within arm's reach
Periodically looking in on the child
Able to hear the child's actions
Other/Refused
Don't know
[IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6, THEN SKIP TO QUESTION 174]
Q.172 Please describe the Other type of supervision the child had at the time of the accident.
____________________________________________________________________________
(8725-8924)
____________________________________________________________________________
____________________________________________________________________________
Q.173 On behalf of the Consumer Product Safety Commission, I would like to thank you for your cooperation
during this interview. If we need to follow-up on this interview, would it be alright for us to get back in
touch with you?
(8925)
q1
q2
Yes
No
Thank you for your time.
End Interview
Q.174 Interviewer: What is the date this interview was completed (MM/DD/YY)?
____________________________________________________________________________
-38-
OMB Control Number 3041-0029
(8926-8935)
| File Type | application/pdf |
| Author | mboudreault |
| File Modified | 2010-03-10 |
| File Created | 2007-07-30 |