Questions to be Cognitively Tested

Attachment 1: Questions to be cognitively tested

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

This is a reduced version of the questionnaire that only includes sections to be cognitively tested. Within this subset, the most important parts of the questionnaire to test are:

• Past 12 months TBI

• Signs/Symptoms

• Lifetime TBI

Inclusion Criteria	Question
Past 12 months TBI
ASK IF ADULT, PROXY, OR DIRECT	RECALL. We are interested in learning about times, in the last year, when [you/your child] experienced an injury to your head or neck. This might have been from a bump, blow or jolt to your head.
ask if adult, proxy, or direct	INJ. In the last year, that is since one year ago from today, [were you/was your child] examined in a doctor’s office, clinic, hospital or elsewhere because of an injury to the head or neck? 1. YES 2. NO
ASK IF ADULT, PROXY, OR DIRECT and INJ =1	INJN. In the last year, that is since one year ago from today], how many times did [you/your child] go to a doctor’s office, clinic, or hospital or [were you/ was your child] examined because of an injury to the head or neck? ENTER COUNT: ______
ASK IF ADULT, PROXY, OR DIRECT	PREJOG. Now I’d like for you to think about [IF YES TO INJ, read “other”] times in the last year when [you/your child] may have experienced an injury to the head or neck. I would like you to tell me about a head or neck injury even if [you/your child] did not go to see a doctor for care. This might have happened while playing a sport for fun or competition, or while [you were/your child was] doing something physically active like bicycling. It might have happened as a result of a car accident or because someone hurt [you/your child]. Or, it could have happened because [you/your child] tripped, slipped, or fell down.
ASK IF ADULT, PROXY, OR DIRECT	INJ2. Other than those you have already reported to me, in the last year, that is since one year ago from today, did [you/your child] experience any other injuries to [your/their] head or neck? 1. YES 2. NO
ASK IF ADULT, PROXY, OR DIRECT and INJ2 =1	INJN2. In the last year, that is since one year ago from today, how many head or neck injuries did [you/your child] experience, not counting the injuries you have already mentioned? ENTER COUNT: ______
transition
ASK IF ADULT, PROXY, OR DIRECT and INJn >=1	PREINTX. Thank you. Now we have some more questions about [your/your child’s] injury.
injury description if more than one injury; note one question is required even if there is only one injury
ASK IF ADULT, PROXY, OR DIRECT and INJN + INJN2 >1	PREOPN. I will be asking you some follow-up questions about these injuries and would like to be able to distinguish [the two injuries/the three injuries/the three most recent injuries].
ASK IF ADULT, PROXY, OR DIRECT and INJN + INJN2 >1	INJOPN1. Can you briefly describe what caused the most recent injury INTERVIEW: write brief DESCRIPTION 01. _______ [ENTER RESPONSE TEXT RANGE= XXXX] 97 DON’T KNOW 99 REFUSED
ASK IF ADULT, PROXY, OR DIRECT and INJN + INJN2 =>1 (need month even if it is only one injury)	MONTH. In what month did the injury occur? 1. JANUARY 2. FEBRUARY 3. MARCH 4. APRIL 5. MAY 6. JUNE 7. JULY 8. AUGUST 9. SEPTEMBER 10. OCTOBER 11. NOVEMBER 12. DECEMBER 97. DON’T KNOW/NOT SURE
Repeat for up to three injuries, then move to signs and symptoms
Signs/Symptoms (Incidence)
ASK if inttype=ADULT, PROXY, OR DIRECT for one to three injuries. if there is more than one injury, repeat this section for up to three injuries-refer to each injury using INJOPN1 and monthn to remind the respondent which injury you are asking about. complete signs/symptoms and next section for one injury before moving to the next injury
ASK if inttype=ADULT, PROXY, OR DIRECT and there is more than one injury	PRESYMMU. Now I’d like to discuss the injuries you told me about. Let’s discuss the one you described as [INJOPN1] that occurred in [MONTHN]. 01. CONTINUE
	PRESYM. In the next set of questions, I will be asking what happened to [you/your child] in the minutes after this injury. For each one I read, please tell me if it happened to [you/your child] or not. We only want to know about things caused by the injury or made worse by the injury. 01. CONTINUE
	SYM1. ADULT: “Were you dazed, foggy, confused, or disoriented?” / PROXY: “Did your child act or appear mentally foggy?” DIRECT: “Did you feel mentally foggy?” 1. YES 2. NO
	SYM2. ADULT: “Did you forget what happened just before or after the injury?”/ PROXY: “Did your child have difficulty remembering what happened just before or after the injury?” / DIRECT: “Did you have difficulty remembering what happened just before or after the injury?” 1. YES 2. NO
	SYM3. ADULT OR DIRECT: “Did you feel sick to your stomach or did you vomit?” / PROXY: “Did your child complain of feeling sick to his or her stomach?” 1. YES 2. NO
	SYM4. ADULT OR DIRECT: “Were you knocked out, blacked out, or did you lose consciousness, even briefly?”/ PROXY: “Was your child knocked out, blacked out, or did you child lose consciousness, even briefly?” 1. YES 2. NO
ASK if sym4=1	SYM4A. For how long? Was it… 1. A few seconds 2. More than a few seconds but less than 5 minutes 2. 5 to 30 minutes 3. 31 to 59 minutes 4. 1 to 24 hours, or 5. More than 24 hours
	PRESYM5. Now we’d like to ask you about things that happen to some people after this kind of injury.  Some of these develop immediately after the injury and some do not happen until hours or days after the injury.   Again, we only want to know about things caused by the injury or made worse by the injury.
	SYM5. ADULT OR DIRECT: “Did you have a headache?” / PROXY: “Did your child complain of a headache?” 1. YES 2. NO
ASK if SYM5=1	SYM5A. Did this occur… 1. Immediately after the injury 2. In the hours or days after the injury, or 3. Both immediately and in the hours or days after the injury?
	SYM6. ADULT: “Was there ever a time when you were dizzy, uncoordinated, had poor balance, were stumbling around, or moved more slowly than usual?” / PROXY: “Did your child appear or complain of dizziness, appear to move in a clumsy manner, or have balance problems?” / DIRECT: “Was there a time when you were dizzy, moved in a clumsy manner, or had balance problems?” 1. YES 2. NO
ASK if SYM6=1	SYM6A. Did this occur… 1. Immediately after the injury 2. In the hours or days after the injury, or 3. Both immediately and in the hours or days after the injury?
	SYM7. ADULT OR DIRECT: “Did you have blurred vision, double vision or changes in your vision?” / PROXY: “Did your child have or complain about visual problems such as blurry or double vision?” 1. YES 2. NO
ASK if SYM7=1	SYM7A. Did this occur… 1. Immediately after the injury 2. In the hours or days after the injury, or 3. Both immediately and in the hours or days after the injury?
	SYM8. Did [you/your child] have trouble concentrating? 1. YES 2. NO
ASK if SYM8=1	SYM8A. Did this occur… 1. Immediately after the injury 2. In the hours or days after the injury, or 3. Both immediately and in the hours or days after the injury?
	PRESYM9. The next questions are about things that might happen to people in the hours or days following this kind of injury.  Again, we are only interested in things caused by the injury, or made worse by the injury. 01. CONTINUE
	SYM9. ADULT: “Did you have difficulty thinking clearly, remembering, or learning new things?” / PROXY: “Did your child become confused with directions or tasks or answer questions more slowly than usual?” / DIRECT: “Did you become confused with directions or tasks, or answer questions more slowly than usual?”] 1. YES 2. NO
	SYM10. ADULT OR DIRECT: “Were you sensitive to light or noise?” / PROXY: “Was your child sensitive to light or noise?” 1. YES 2. NO
	SYM11. ADULT OR DIRECT: “Did you experience a change in mood or personality such as irritability, changes in emotional responses, or feeling more bothered by things?” / PROXY “Did your child act more or less emotional than usual, more irritable, or more bothered by things?” 1. YES 2. NO
	SYM12. ADULT: “Did you have trouble with sleep? Such as, did you have trouble falling asleep, were you more drowsy than usual, did you get tired easily or more frequently than usual, or did you sleep noticeably more or less than usual?” / PROXY: “Did your child appear drowsy, sleep more than usual or appear more tired or fatigued?” / DIRECT: “Did you feel drowsy, sleep more than usual or feel more tired or fatigued?” 1. YES 2. NO
CASE DEFINITION: if the respondent endorsed at least one symptom for this injury, go to srrx. If not, and there is more than one injury, go back through signs/symptoms for the next injury. If there is not at least one symptom for this injury and there are no more injuries, go to lifetime tbi or concussion
SRR Activity (SRR Incidence)
ASK if inttype=ADULT, PROXY, OR DIRECT for one to three injuries. if THERE IS AT LEAST ONE SIGN/SYMPTOM FOR AN INJURY AND there is more than one injury, ASK THIS QUESTION DIRECTLY AFTER THE SIGNS/SYMPTOM SECTION FOR EACH INJURY AND THEN RETURN TO SIGNS/SYMPTOMS FOR THE NEXT INJURY.	SRRX. Did [you/your child] experience this injury while playing a sport, or while engaged in physical fitness or recreational activity for fun or competition? Please do not include chores performed in or around the house. 1. YES 2. NO
THE FOLLOWING SECTIONS SHOULD ONLY BE ASKED FOR THE MOST RECENT INJURY
Military
ask if inttype=aDULT and THE RESPONDENT WAS IN THE MILITARY DURING THE PAST 12 MONTHS (THIS QUESTION WAS IN THE DEMOGRAPHIC SECTION REMOVED FOR COGNITIVE TESTING)	MILX. Did this injury occur during military service? 1. YES 2. NO
ask if inttype=adult and milX=1	MILWHENX. In what setting did your injury occur? Did it occur…? 1. While deployed to a combat zone 2. While deployed to a non-combat zone 3. During military training 4, While on-duty, but not while deployed or training 5. While off-duty, or 95. In another setting
ask if inttype=adult and milX=1	MILBLASTX. Was your injury due to a blast or explosion? 1. YES 2. NO
Intentionality
ask if INTTYPE=ADULT, PROXY, OR DIRECT and milblastx<>1	INTENTX. Which of the following best describes how the injury happened? Would you say that… 1. Someone else injured [you/your child] on purpose 2. [You/your child] tried to injure [yourself/him or herself] 3. It was an accident—no one intended to injure [you/your child], or 95. Something else happened?
Bike
ask if INTTYPE=ADULT, PROXY, OR DIRECT and milblastx<>1 and srr = 2	BIKEX. Did [you/your child] experience this injury while on a bicycle or a self-propelled wheeled vehicle? 1. YES 2. NO
ask if INTTYPE=ADULT, PROXY, OR DIRECT and BIKEX=1 or (srrx=1 and bike)	BIKE1X. How did the injury happen? Was it due to a… 1. Collision with a moving motor vehicle 2. Collision with another bicycle 3. Collision with a person 4. Collision with a stationary object 5. Fall from bicycle to surface (e.g., road, bike path, etc.), or 95. Something else?
ask if INTTYPE=ADULT, PROXY, OR DIRECT and BIKEX=1 and srrx <>1	BIKE4X. What was the PRIMARY reason [you were/ your child was] bicycling at the time of the injury? [Were you/Was your child]… 1. Riding primarily as a means of transportation (e.g., to get to work, to get to school, etc.) 2. Riding primarily for recreation, physical fitness, or competition 97. DON’T KNOW
Motor Vehicle
ask if INTTYPE=ADULT, PROXY, OR DIRECT nd milblastx<>1 and bikex=2	MVX. Did [you/your child] experience this injury while on or in a motorized vehicle, such as a car, bus, motorcycle, dune buggy, or all-terrain vehicle (ATV)? 1. YES 2. NO
ask if INTTYPE=ADULT, PROXY, OR DIRECT and MV1X=1 or (srrx = 1 and motor vehicle)	MV3X. What type of vehicle [were you in/was your child in]? 1. An ATV, off-road vehicle or dune buggy 2. A bus or truck 3. A car 4. A motorcycle or dirt bike 5. A personal water craft (i.e., Jet ski, ski doo) 6. Other 95. Another type of vehicle [ENTER RESPONSE TEXT RANGE=XXXX]
ask if INTTYPE=ADULT, PROXY, OR DIRECT and MV3X=1, 2 OR 3	MV2X. Were [you/your child] wearing a seatbelt at the time of the injury? 1. YES 2. NO
ask if INTTYPE=ADULT, PROXY, OR DIRECT and mvX=1	MV6X. Which of the following best describes how the injury occurred? Did [you/your child] collide with… 1. Another motor vehicle 2. A stationary object 3. An animal (e.g. a deer), or 95. Something else [ENTER RESPONSE TEXT RANGE=XXXX]
ask if inttype=a and mvX=1 and srrx<>1 and MV3X = 1, 4, or 5	MV7X. Why [were you/was your child] riding or driving at the time of the injury? [Were you/was your child] 1. Riding or driving as a means of transportation (e.g., to get to work, to get to school, etc.) 2. Riding or driving for fun, for pleasure, or for competition
Other Cause
ask if INTTYPE=ADULT, PROXY, OR DIRECT and srrx=2 and milblastx<>1 and bike = 2 and mvx = 2	CAUSEX. Would you say that the injury occured because you … Fell without being struck or pushed Were hit by an object or person, or were pushed against something? 95. Something else [ENTER RESPONSE TEXT RANGE=XXXX]
Falls
ask if INTTYPE=ADULT, PROXY, OR DIRECT and causex = 1	FALLX. Did [you/ your child] fall… 1. From the floor or from ground level, like a trip or slip 2. Down the stairs 3. From a height less than or equal to 10 feet, or 4. From a height greater than 10 feet
Location
ask if INTTYPE=ADULT, PROXY, OR DIRECT	LOCX Did this injury occur… 1. At your home 2. On a street 3. At a school 5. Park or recreational area 4. At a sports field or complex 6. Somewhere else? ENTER TEXT: ________________
ASK if inttype = adult	WORK Were you working for pay when the injury occurred? 1. YES 2. NO
SRR General Cause
ask if INTTYPE=ADULT, PROXY, OR DIRECT and srrx=1	CAUSEX2. What initially caused the injury? For example, if two individuals collided, and then made contact with the ground, the initial contact would be with another person. Was the injury initially due to contact with… 1. Another person 2. The ground 3. An object that was part of the activity like a ball or a goal 4. An object that was not part of the activity like the bleachers or a tree 95. Something else [ENTER RESPONSE TEXT RANGE = XXX]
Still Experiencing S/S
ASK if inttype=adult, proxy or direct	SYMSTILL. [Are you/Is your child] still experiencing any of the injury-related symptoms that we’ve talked about? 1. YES 2. NO
ASK if inttype=adult, proxy or direct and SYMstill=2	SYMRECA. How long did it take for [you/your child] to recover from all of [your/their] injury-related symptoms? OPEN ENDED XX Days XX Weeks XX Months
ASK if inttype= proxy and	CHILDPRES. Did you ask your child about any of their signs or symptoms during our call? 1. YES 2. NO
Medical Care Adult or Proxy	ask if inttype = adult or proxy unless otherwise specified
	PREMED. We have some questions about medical care [you/your child] may have received because of this injury. First [were you/was your child] examined in doctor’s office, clinic, hospital or elsewhere? 1. YES 2. NO 97. DK/NR DON’T KNOW/NOT SURE
ask if premed=1	EVWHOX. Who first looked at or examined [you/your child] after receiving this injury. ? Was it… 1. A nurse 2. A doctor 3. A psychologist 4. An athletic trainer 5. Emergency Medical Services (EMS) 95. Someone else [ENTER RESPONSE [TEXT RANGE = XXX] 97. DK/NR
ask premed=1	EVTIMEX. How long after the injury [were you/was your child] first evaluated by [see answer to previous question]? Was it… 1. At the time and place of the injury 2. After the time of the injury, but within 24 hours 3. Within 1 week 4. More than 1 week later
ask if evtimeX=2, 3, or 4	EVWHEREX. Where did the first evaluation take place? 1. In a doctor’s office or clinic 2. At a hospital or emergency department 95. Or somewhere else [ENTER RESPONSE [TEXT RANGE = XXX]
ask if evwhereX=1 or 95	DOCX. Did the first evaluation take place at…? 1. [Your/your child’s] regular doctor or primary care physician’s office 2. An urgent care clinic 3. A clinic in a pharmacy or grocery store 4. A sports medicine clinic 5. A concussion clinic, or 95. Some other place? [ENTER RESPONSE [TEXT RANGE = XXX]
ask if evwhereX=2	HOSPX. Did the first evaluation take place at…? 1. An emergency room 2. An outpatient clinic in a hospital 3. A sports medicine clinic in a hospital 4. An urgent care clinic in a hospital, or 5. At another location in a hospital [ENTER RESPONSE [TEXT RANGE = XXX] 97. DK/NR
ask if inttype = adult	MILCAREX. Did [you/your child] receive any type of health, medical, or rehabilitation care for [your/your child’s] injury through the Department of Veteran Affairs? Would you say… 1. Yes, directly from a VA hospital, clinic or VA program (e.g., Vocational Rehabilitation & Employment program) 2. Yes, from a civilian provider/facility, but paid for by VA (e.g., Veterans Choice card, etc.), or 3. No
ask if premed=1	CAREX. Did you receive care for [your/your child’s] injury after the initial examination? 1. YES 2. NO 97. DK/NR DON’T KNOW/NOT SURE
ask if carex = 1	CAREAX. Did [you/your child] receive care from [your/your child’s] regular doctor or primary care physician? 1. YES 2. NO 97. DK/NR DON’T KNOW/NOT SURE
ask if carex = 1	CAREBX. What about an urgent care clinic? IF NEEDED: “Did [you/your child] receive care from… 1. YES 2. NO
ask if carex = 1	CARECX. A clinic in a pharmacy or grocery store? IF NEEDED: “Did [you/your child] receive care from… 1. YES 2. NO
ask if carex = 1	CAREDX. A sports medicine clinic? IF NEEDED: “Did [you/your child] receive care from… 1. YES 2. NO
ask if carex = 1	CAREEX. A concussion clinic? IF NEEDED: “Did [you/your child] receive care from… 1. YES 2. NO
ask if carex = 1	CAREFX. A hospital or emergency department? IF NEEDED: “Did [you/your child] receive care from… 1. YES 2. NO
ask if premed=1	TBIDX. Following this injury, did a medical professional diagnose [you/your child] with a concussion or traumatic brain injury? 1. YES 2. NO
ask if premed=2 and careax through caregx are all 2, 97 or 99 [and if milcurr = 1 or milever=1 and MILCAREX=3]	WHYNOCRX. Sometimes it is very difficult for people to receive the health care that they need or want [for their child]. Please select the primary reason [you/your child] did not receive health care for this injury. You had difficulty paying for it 2. You did not have transportation 3. You could not take time off work 4. You did not think the injury [to your child] was serious
ask if WHYNOCRX = 1	WHYNOCRAX. Was it difficult to pay for because … [You/your child] did not have health insurance [You/your child] had insurance, but you could not or did not want to pay the amount you were responsible for 3. You did not have authorization from your insurance
ask if evwherex=1 or carefx=1	HOSPSTAX. Did [you/your child] stay in a hospital overnight or longer because of the injury? 1. YES 2. NO
ask if HOSPSTAx=1	HOSPNITEX. How many nights did [you/your child] stay in the hospital because of the injury? 1. GAVE ANSWER [ENTER RESPONSE MIX TO MAX DAYS]
ask if HOSPSTAx=1	HOSPTRX. After [you were/your child was] discharged from the hospital, did [you/your child] receive inpatient rehabilitation care from a rehabilitation center or nursing care facility because of this brain injury? 1. YES 2. NO 9. REFUSED
ask if premed=1	RECSERVX. IF HOSPITALIZED: [After your hospitalization/After your child’s hospitalization] IF NOT HOSPITALIZED: After this injury], did [you/your child] receive services to help get well? Some examples might include physical therapy, speech therapy, vocational rehabilitation, neuropsychological services, or counseling. 1. YES 2. NO
Medical Care Direct	ask if inttype = Direct
	DASSESSED. Did anyone check you out to see if you were injured? 1. YES 2. NO
ask if DASSESSED =1	DBYWHOA. Who were you first assessed by? 1.    A school nurse 2.     An athletic trainer 3.     A coach 4.     A parent 5.     Emergency Medical Services (EMS) 6.     Your regular doctor or pediatrician 7.     A specialist (e.g. sports medicine doctor, neurologist) 8.     Another medical professional, or 95.   Someone else [ENTER RESPONSE [TEXT RANGE = XXX] 97.   DK/NR 99.   REFUSED
ask if dassessed = 1 and DBYWHOA =2, 3, or 4	DBYWHOB.  After you were checked out by [state from previous question response], were you checked out by any of the following people? Please say “yes” or “no” to each one. 1.          Your regular doctor or pediatrician 2.           A specialist (e.g. sports medicine doctor, neurologist) 3.            Another medical professional, or 95.         Someone else [ENTER RESPONSE [TEXT RANGE = XXX] 97.         DK/NR 99.         REFUSED
ask if DASSESSED =2 and (SRRSET1X=1 or SRRSET3X=1)	PRETELL. Although you were not checked out for your injury, did you tell anyone? 1. YES 2. NO
ask if PRETELL = 1 and (SRRSET1X=1 or SRRSET3X=1)	TELLCOACH. Did you tell a coach? 1. YES 2. NO
ask if PRETELL = 1 and (SRRSET1X=1 or SRRSET3X=1)	TELLTEAM. A Teammate? 1. YES 2. NO
ask if PRETELL = 1	TELLPARENTS. Your parents? 1. YES 2. NO
ask if PRETELL = 1	TELLDOCTOR. A doctor? 1. YES 2. NO
ask if PRETELL = 1	TELLELSE. Someone else? 1. YES 2. NO
ask if all “tell” above = no	NOTELLWHY. Why did you choose not to tell anyone? Was it because you… interviewer: open ended, code response, select all that apply. Did not realize you were injured Did not think the injury was serious Did not want to be removed from your sport 95.         Some other reason [ENTER RESPONSE [TEXT RANGE = XXX] 97. DK/NR
Child and Adult Return to Play
ask if (inttype = proxy or intype =adult and age1 =18-21) and SRRSET1X=1	REMPLAYX. [Were you/was your child] removed from the game, performance, or practice as a result of the injury? 1. YES 2. NO 97. DON’T KNOW/NOTSURE
ask if (inttype = proxy or intype =adult and age1 =18-21) and REMPLAYX= 1	REMWHOX. Who removed [you/your child] from play? 1. A doctor 2. An athletic trainer 3. An EMT or EMS 4. The Coach 5. A Parent 6. An official or referee 7. You removed [yourself/your child] from play 95. Other
ask if (inttype = proxy or intype =adult and age1 =18-21) and REMPLAYX = 1	RETURNX. [Have you/Has your child] returned to full sports/recreation activity following the injury? 1. YES 2. NO
ask if (inttype = proxy or intype =adult and age1 =18-21) and returnX= 1	RETWHENX. Did [you/your child] return to full sports/recreation activity in…? OPEN ENDED XX Days XX Weeks XX Months
ask if (inttype = proxy or intype =adult and age1 =18-21) and returnX= 1	CLEARED. [Were/was] [you/your child] cleared by a doctor to return to play? 1. YES 2. NO
ask if cleared = 2	RETWHOX. Who made the decision to allow [you/your child] to return to play? 2. An athletic trainer 3. An EMT or EMS 4. A coach 5. A Parent 6. An official or referee 7. You made the decision [IF INTTYPE=P READ “for your child”] to return to activity following the injury 95. Other
ask if cleared = 1	RETWHOAX. What kind of doctor made the decision for [you/your child] to return to activity? Was it a… 1. A primary care provider 2. A sports medicine physician 3. An emergency department physician 4. A neuropsychologist or neurologist 5. Another type of health care provider [ENTER RESPONSE [TEXT RANGE = XXX]
Child Proxy Return to School	ask if inttype = proxy
	SCHOMISS. Did your child miss any school due to the injury? 1. YES 2. NO
ask if schomiss=1	SCHOMISSA. How many days? __________ENTER RESPONSE [RANGE = 1-XX]
ask if schomiss =1	SCHOREC. Did your child’s health care provider make any recommendations about how you, school personnel or your child’s teachers could help your child return to school? 1. YES 2. NO
ask if schomiss =1 and schorec=1	SHAREREC. Were these recommendations shared with the school? 1. YES 2. NO
	TEACHTOL. Were your child’s teacher(s) told about your child’s injury? 1. YES 2. NO
	EXTHELP. Did your child receive extra help, support, or services at school due to the injury? 1. YES 2. NO
ask if EXTHELP=1	RETLNGHT For how long did your child receive this help? OPEN ENDED XX Days XX Weeks XX Months
ask if inttype = p	ACPERF. Has your child’s grades declined since the injury? 1. YES 2. NO
ask if acperf = 1	ACPERF2. Is the decline in grades due to the injury? 1. YES 2. NO
ask if acperf = 2	ACPERF3. Is your child having to work harder for the grades he or she had prior to the injury? 1. YES 2. NO
Adult Return to Work	ask if inttype = a
	WKMISSX. Did the injury cause you to miss or stop work that you do for pay? 1. YES 2. NO
	HMMISSX. Did the injury cause you to miss or stop other responsibilities you have, like taking care of your family or volunteer work? 1. YES 2. NO
Lifetime TBI or Concussion	All respondents receive this section, regardless of whether they have reported a head injury in the last 12 months
ask if INTTYPE=ADULT, PROXY, OR DIRECT	LIFETBIDX. IF THERE WAS AN INJURY IN THE LAST 12 MONTHS: “Other than what you have already reported” Thinking across [your/ your child’s” entire life, has a doctor, nurse, or other medical professional ever told [you/ your child] that [you/ he or she] had a concussion or any other type of brain injury caused by a blow to the head? 1. YES 2. NO
ASK IF ADULT, PROXY, OR DIRECT and LIFETBIDX=1	LIFETBIDXN. How many concussions, or other types of brain injury caused by a blow to the head, [have you/has your child] had in [your/his or her] lifetime? ENTER NUMBER [RANGE=MIN-MAX]
ASK IF ADULT, PROXY, OR DIRECT	TBINODX1. A concussion has occurred anytime a blow to the head caused [you/your child] to have symptoms, whether just momentarily or lasting awhile. Symptoms include: blurred or double vision, seeing stars, sensitivity to light or noise, headaches, dizziness or balance problems, nausea, vomiting, trouble sleeping, fatigue, confusion, difficulty remembering, difficulty concentrating, or being knocked out. IF THERE WAS AN INJURY IN THE LAST 12 MONTHS: “Other than what you have already reported in the last 12 months” In [your/your child’s] lifetime, do you believe that [you have/your child has] ever had a concussion or other type of brain injury other than those diagnosed by a medical professional? 1. YES 2. NO
ASK IF ADULT, PROXY, OR DIRECT and LIFETBIDX=1	TBINODXN. How many non-diagnosed concussions, or other type of brain injury [have you/has your child] had in [your/his or her] lifetime? ENTER NUMBER [RANGE=MIN-MAX]
ASK IF ADULT, PROXY, OR DIRECT and LIFETBIDXN + TBINODX1 >= 1	LTSRR. [Was this/Were any of these] concussions experienced while participating in sports or a recreational activity for fun or competition? 1. YES 2. NO
ask if inttype = ADULT and (LIFETBIDX>1 OR TBINODX > 1)	AGETBI. How old were you at the time of [this/the first] brain injury or concussion ENTER AGE [RANGE=MIN-MAX]

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