Questionnaire - Injury Questions to Evaluate

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(d)) 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

	Version 1 (Ask about injuries with no examples)
INJ1	The next set of questions asks about injuries. People can be injured accidentally, or on purpose. They may hurt themselves or others may cause them to be hurt.
INJ2	The first question is about repetitive strain injuries. By this, we mean injuries caused by repeating the same movement over an extended period. Examples include carpal tunnel syndrome, tennis elbow, or tendonitis. DURING THE PAST 3 MONTHS, did you have any injuries due to repetitive strain?
INJ3	If INJ2=no continue to INJ4 If INJ2=yes: Were any repetitive strain injuries serious enough to limit your usual activities for at least 24 hours? DURING THE PAST 3 MONTHS, did you miss any days of work or school because of repetitive strain injuries? Did you talk to or see a doctor or other health professional about any repetitive strain injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, what was the worst amount of pain that you had from your repetitive strain injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, overall during the last 3 months how much pain did you have on average from your repetitive strain injuries?
INJ4	[Not including any of the repetitive strain injuries you just told me about,] DURING THE PAST 3 MONTHS, did you have an accident or an injury where any part of your body was hurt?
INJ5	If INJ4=yes go to INJ6 If INJ4= no: Some people may forget about common injuries. So, even though you just told me that you have not had any injuries, I would like to ask a few more questions just to be sure. DURING THE PAST 3 MONTHS, did you have any injuries as a result of a fall or falling? DURING THE PAST 3 MONTHS, did you have any injuries as a result of a collision involving a motor vehicle? DURING THE PAST 3 MONTHS, did you have any injuries as a result of hitting or being hit by a person or object? DURING THE PAST 3 MONTHS, did you have any injuries while you were playing sports or exercising, including walking, biking, or running for exercise? Please also include recreational sports such as skating, skiing, tennis, golf, bowling, or fishing. DURING THE PAST 3 MONTHS, did you have any injuries while you were working at a job or business? DURING THE PAST 3 MONTHS, did you have any injuries while you were at home? DURING THE PAST 3 MONTHS did you have any injuries while you were in a public place such as a park or school? (If all no, end interview. If any yes, go to “yes” follow-up questions.)
INJ6	If yes: Were any of these injuries serious enough to limit your usual activities for at least 24 hours after the injury occurred? Were any of these injuries serious enough that you missed at least one day of work or school? Did you see or talk to a doctor or other health professional about any of these injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, what was the worst amount of pain that you had from your injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, overall during the last 3 months how much pain did you have on average from your injuries?
	Version 2 (Use examples of injuries)
INJ1A	The next set of questions asks about injuries. People can be injured accidentally, or on purpose. They may hurt themselves or others may cause them to be hurt.
INJ2A	The first question is about repetitive strain injuries caused by repeating the same movement over an extended period. DURING THE PAST 3 MONTHS, did you have any injuries due to repetitive strain such as carpal tunnel syndrome, tennis elbow, or tendonitis?
INJ3A	If yes: Were any repetitive strain injuries serious enough to limit your usual activities for at least 24 hours? DURING THE PAST 3 MONTHS, did you miss any days of work or school because of repetitive strain injuries? Did you talk to or see a doctor or other health professional about any repetitive strain injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, what was the worst amount of pain that you had from your repetitive strain injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, overall during the last 3 months how much pain did you have on average from your repetitive strain injuries?
INJ4A	[Not including any of the repetitive strain injuries you just told me about,] DURING THE PAST 3 MONTHS, did you have a broken bone, sprain, burn, wound, cut, bruise, concussion, animal bite, or any other type of injury?
INJ5A	If no: Some people may forget about common injuries. So, even though you just told me that you have not had any injuries, I would like to ask a few more questions just to be sure. DURING THE PAST 3 MONTHS, did you have any injuries as a result of a fall or falling? DURING THE PAST 3 MONTHS, did you have any injuries as a result of a collision involving a motor vehicle? DURING THE PAST 3 MONTHS, did you have any injuries as a result of hitting or being hit by a person or object? DURING THE PAST 3 MONTHS, did you have any injuries while you were playing sports or exercising, including walking, biking, or running for exercise? Please also include recreational sports such as skating, skiing, tennis, golf, bowling, or fishing. DURING THE PAST 3 MONTHS, did you have any injuries while you were working at a job or business? DURING THE PAST 3 MONTHS, did you have any injuries while you were at home? DURING THE PAST 3 MONTHS did you have any injuries while you were in a public place such as a park or school? (If all no, end interview. If any yes, go to “yes” follow-up questions.)
INJ6A	If yes: Were any of these injuries serious enough to limit your usual activities for at least 24 hours after the injury occurred? Were any of these injuries serious enough that you missed at least one day of work or school? Did you see or talk to a doctor or other health professional about any of these injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, what was the worst amount of pain that you had from your injuries? On a scale from 1 to 10 where 1 means no pain at all and 10 means the pain was as bad as it could be, overall during the last 3 months how much pain did you have on average from your injuries?

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