Appx 2 General Survey SAMPLE

Appx 2 GenSurvey_SAMPLE_March 2_Clean.docx

Assessment of Chemical Exposures (ACE) Investigations - FY2016 Q2 Burden Report

Appx 2 General Survey SAMPLE

OMB: 0923-0051

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0923-0051 can be found here:

Document [docx]

Download: docx | pdf

Shape2

Appendix 2: General Survey

Shape3

Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Interviewer__________ Household ID___________ Participant ID ___________

Date _____________ Start time _____________ End time ______________

Participant Name: _________________________________________________________

Shape4

SECTION I: ADULT SURVEY

General Survey Module A: Location/Exposure

I would like to begin by showing you a map of the areas affected by [Description of Incident] on [Date]. The affected areas are highlighted. From now on, I will refer to the [Description of Incident] on [Date] as “the incident.”

After reviewing a map of the exposed area(s), ask respondents the following questions:

Were you in this area at any time between [Incident Date/Time] and [End Date/Time]?

Shape5 Yes

Shape6 No Say to the respondent: Thank you for your time.

Record the end time and do not ask any further questions. This person is not eligible for the survey.

I would like to know about each place you went within the highlighted area on the map between [Incident Date] at [Time] and [End Date/Time] so that I can construct a timeline and understand what happened when you were exposed. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location.

Shape8 Shape7

Public reporting burden of this collection of information is estimated to average 30 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)

	Location 1:	Location 2:	Location 3:
What is the address of where you (first/next) were during the incident? Probe for as much location information as possible. Then, continue to b. Do not ask about all locations first. Collect all information about one location before continuing to the next.
How long were you in this location? Record whether in minutes or hours.
Were you inside or outside while you were there? If outside, skip questions d, e, and f.	In Out	In Out	In Out
If inside, were there any open windows while you were there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If inside, was there any ventilation, such as an [air conditioner/heater] running, while you were there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If respondent said “yes” for d or e, circle “no” for f and skip to next question. Otherwise, if inside, ask: did you shelter in place, meaning staying inside, with doors and windows closed and all ventilation systems turned off? If yes, ask the respondent: Please describe what you did to shelter in place.	Yes No Unsure	Yes No Unsure	Yes No Unsure
Did you smell an odor? If no or unsure skip questions h and i.	Yes No Unsure	Yes No Unsure	Yes No Unsure
Can you please describe the odor?
Would you describe the odor as light, moderate or severe?	Light Moderate Severe	Light Moderate Severe	Light Moderate Severe
Were you in a [smoke cloud/dust/fog] while you were there?	Yes No Unsure	Yes No Unsure	Yes No Unsure

Did you evacuate from the highlighted area on the map?

Shape9 Yes

Shape11 No Go to Question A5

At approximately what time did you evacuate?

____:_____ Shape12 AM Shape13 PM

Hour Min

How did you evacuate?

Shape14 Ambulance

Shape15 Privately-owned vehicle

Shape16 Bus

Shape17 Other (Please specify):

Is there any additional information that you think we should know about your exposure?

Shape18 Yes Record the information on the lines provided below

Shape20 No Continue to Question A7

Were you decontaminated, meaning your clothing was removed or your body was washed?

Shape21 Yes

Shape23 No Go to next module

How were you decontaminated? Read all answer choices aloud to the respondent and check all that apply.

Shape24 Clothing Removal

Shape25 Water

Shape26 Soap and Water

Shape27 Other (Please specify):

Where were you decontaminated? If respondent needs clarification, specify that this question is asking for a geographic location, not a place on their body.

At approximately what time were you decontaminated?

____:_____ Shape28 AM Shape29 PM

Hour Min

General Survey Module B: Health status

Now I would like to ask you some questions about any symptoms you may have experienced after the incident.

Within 24 hours of the incident, did you have any symptoms of an illness?

Shape30 Yes

Shape32 No Go to next module

I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom.

	Did you experience [Symptom] within 24-hours of the incident? If yes, go to ii. If no, repeat i for next symptom.		Were you experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.		Was your [Symptom] worse after the incident? Continue to iv (if listed); otherwise, repeat i for next symptom.		Are you still experiencing [Symptom]? Repeat i for next symptom.
Symptom	Yes	No	Yes	No	Yes	No	Yes	No
Irritation/pain/ burning of eyes
Increased tearing
Blurred vision/double vision
Runny nose
Burning nose or throat
Burning lungs
Increased salivation
Ringing of the ears
Difficulty swallowing
Odor on breath (Gasoline or other, specify)
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Difficulty concentrating
Weakness of arms
Weakness of legs
Muscle twitching
Tremors in arms or legs
Loss of balance
Breathing slow
Breathing fast
Difficulty breathing/feeling out-of-breath
Coughing
Increased congestion or phlegm
Wheezing in chest
Slow heart rate/pulse
Fast heart rate/pulse
Chest tightness or pain/angina
Blue or gray coloring of ends of fingers/toes or lips
Nausea
Non-bloody vomiting
Non-bloody diarrhea
Bloody vomiting
Blood in stool/diarrhea
Abdominal pain
Fecal incontinence or inability to control bowel movements
Irritation, pain, or burning of skin
Skin rash
Skin blisters
Sweating
Cool or pale skin
Skin discoloration
Anxiety
Agitation/irritability
Fatigue/tiredness
Difficulty sleeping
Feeling depressed
Generalized weakness
Diffuse muscle aches and pains
Hallucinations
Urinary incontinence or dribbling pee
Inability to urinate or pee
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

General Survey Module C: Fire/Explosion

Were you injured as a result of the fire or explosion?

Shape33 Yes

Shape35 No Go to next module

I’m going to ask you some questions about injuries that can happen as a result of a fire or explosion. For some of these injuries, I’m going to ask you where on your body they were located. Fill out the table below. Repeat C2 i-ii for one injury and check the boxes that apply before asking about the next injury.

	Did you experience [Injury] within 24-hours after the fire or explosion? If yes, go to C2 ii. If no, repeat C2 i for next injury.		If Yes, where on your body was it located? Repeat C2 i for next injury.
Injury	Yes	No
Abrasion/scrape
Broken bone/fracture
Bruise
Cut
Dislocation
Sprain or strain
Burn
Crush injury
Severe bleeding
Ear drum puncture
Hearing loss
Ringing in ears
Whiplash
Concussion
Bowel perforation
Eye injury
Any other injuries? If yes, what was it? If applicable, specify where on your body was it located? Record below.
1.
2.

General Survey Module D: Medical Care

Did you receive medical care or a medical evaluation because of the incident?

Shape39 Yes  Go to Question D3

Shape40 No

Why didn’t you seek medical care?

Shape41 Did not have symptoms

Shape42 Symptoms were not bad enough

Shape43 Don’t like to go to the doctor

Shape44 Didn’t want to take time

Shape45 Worried about who would pay for the medical visit

Shape46 Worried about losing job

Shape47 Other (Please specify): ______________________________________________

Shape48 Unsure

For those individuals who did not seek medical care, go to the next module.

Were you provided with care by an EMT or paramedic?

Shape50 Yes

Shape52 No  Go to Question D5

On what date were you provided care by an EMT or paramedic?

____/____/______

MM DD YYYY

Were you provided with care at a hospital?

Shape53 Yes

Shape55 No  Go to Question D15

On what date were you first provided care at a hospital? If you had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the respondent first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

What is the name of the hospital(s)?

How did you get to the hospital? If the respondent had more than one hospital visit, tell them that you are referring to their first visit.

Shape56 EMS/Ambulance

Shape57 Drove self

Shape58 Driven by relative, friend, or acquaintance

Shape59 Other (Please specify):

Were you treated only in the emergency department or were you admitted to the hospital?

Shape61 Treated in emergency department (Outpatient)  Go to Question D15

Shape62 Admitted (Hospitalized)

How many nights were you hospitalized, including any nights in an intensive care unit (ICU)?

________ Nights

Were you placed in an Intensive Care Unit or ICU?

Shape63 Yes

Shape65 No  Go to Question D15

How many nights were you in the ICU?

________ Nights

Were you on a ventilator?

Shape66 Yes

Shape68 No  Go to Question D15

How many nights were you on a ventilator?

________ Nights

Besides at a hospital or by an EMT or paramedic, were you seen by a doctor or other medical professional?

Shape69 Yes

Shape71 No  Go to Question D17

Read i-iv to the respondent and record information in the table below.

On what dates were you provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or other medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

Were you prescribed any new medicines when you were examined after the incident?

Shape72 Yes

Shape74 No  Go to Question D19

What is the name of the medicine or medicines you were prescribed? If respondent does not know the name of the medication, ask: What is the medicine for?

Please tell me if any of the following describe why you sought medical care. Read questions a-c to the respondent and circle the appropriate answer(s).
1. You were given instructions to seek medical care? Yes No Unsure
2. You experienced health problems or symptoms
  within 24 hours of the incident? Yes No Unsure
3. You were worried about possible health
  problems associated with the incident? Yes No Unsure

If aged 13-17, read: We will be doing medical chart reviews and will be asking your parent or guardian for permission to review your medical record for the visit related to the incident. Continue to next module.

If aged 18 or older, go to Question D20.

If aged 18 or older, read: To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your medical records for the medical treatment you received because of the incident?

Shape77 Yes  Review the medical records release form with the respondent and collect their signature

Shape78 No

General Survey Module E: Occupational History

Now I’m going to ask you some questions about your work experiences—paid, volunteer, or military—from [12 months ago] to [current date]. This includes part-time and full-time jobs that lasted one month or more, such as jobs for pay inside or outside the home or jobs on a farm.

Are you currently employed?

Shape82 Yes Go to Question E3

Shape83 No

Did you have a job in the last 12 months, that is, since [12 months ago]?

Shape84 Yes

Shape86 No Go to Question E4

If you had more than one job in the last 12 months, please tell me about the most recent job first, then the next most recent. Fill-out the table below; complete the information for the first job completely before asking about the next job. Once information about all jobs that the respondent has had in the past 12 months has been collected, continue to Question E4.

	Job 1	Job 2
What (is/was) the name of the company you (work/worked) for?
What (does/did) this company make or do?
What (is/was) your job title?
(Does/Did) this job include working with or around any chemicals? If no or unsure, go to f.	Yes No Unsure	Yes No Unsure
If yes, what chemicals (do/did) you work with or around?
Did you have any other jobs since [12 months ago]? Yes Repeat E3 for the next, most recent job (If the interviewee has had more than 2 jobs, write details on a supplemental table). Circle ‘yes’ if you need to write information about a job on a supplemental table. Circle ‘no’ if all information collected is contained in this table. Once information about all jobs that the respondent has had in the past 12 months has been collected, continue to Question E4. No Continue to Question F1

General Survey Module F: Medical History

Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used.

Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
Allergies?	Yes (Please specify) ______________________ No Unsure
Asthma?	Yes No Unsure
Diabetes?	Yes No Unsure
High blood pressure?	Yes No Unsure
Chronic obstructive pulmonary disease (COPD) or emphysema?	Yes No Unsure
Heart Disease?	Yes No Unsure
Physical disability that hinders mobility?	Yes (Please specify)_______________________ No Unsure
Psychological condition such as anxiety, depression or dependence disorder?	Yes (Please specify) ______________________ No Unsure
Cancer?	Yes (Please specify) _____________________ No Unsure
Immune disorders such as lupus, rheumatoid arthritis, or HIV?	Yes No Unsure
Neurological conditions such as Parkinson’s disease or multiple sclerosis?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _____________________ No Unsure

Prior to the incident, were you taking any medicines? This includes medicines prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives.

Shape89 Yes

Shape91 No Go to Question F4

Shape93 Don’t Know Go to Question F4

What medicines were you taking? If respondent does not know the name of the medication, ask: What was the medicine for?

Do you currently smoke cigarettes, cigars, or pipes?

Shape95 Yes Go to instruction box before Question F7

Shape96 No

Have you smoked regularly in the past?

Shape97 Yes

Shape99 No Go to instruction box before Question F7

When did you last quit? Was it…Read all choices to the respondent.

Shape100 Less than one year ago

Shape101 1–2 years ago

Shape102 3–4 years ago

Shape103 5 or more years ago

If respondent is male, go to next module

Are you currently pregnant?

Shape105 Yes

Shape106 No

Shape107 Don’t Know

Are you currently breastfeeding?

Shape108 Yes

Shape109 No

General Survey Module G: Emergency Response

Were you a firefighter, police officer, or other professional who responded to the incident? If yes and necessary, probe for type of responder.

Shape112 Firefighter

Shape113 Police officer

Shape114 EMS responder

Shape115 Hospital emergency department worker

Shape116 Other: Please specify

Shape118 Not a responder  Go to next module

What specifically was your role during the response?

If an EMS responder, hospital emergency department worker, or other health care provider, go to Question G4. Otherwise, continue to Question G3.

Please look at this list and tell me what level of PPE you were wearing when you responded to the incident. Present Showcard Side A.

Shape120 None

Shape121 Level “A”

Shape122 Level “B”

Shape123 Level “C”

Shape124 Level “D”

Shape125 Firefighter turn-out gear with respiratory protection.

Shape126 Firefighter turn-out gear without respiratory protection.

Shape127 Other types of protection (such as gloves, eye protection, hardhat, steel-toed shoes)

If selected, ask: Please specify the type of protection:

Shape128 Go to next module

If an EMS responder, hospital emergency department worker, or other health care provider, go to Question G4. Otherwise, continue to next module.

Please look at this list and tell me what type of protection you were wearing.
Present Showcard Side B

Shape130 None

Shape131 Non-sterile exam gloves

Shape132 Surgical gloves

Shape133 Face mask without protective shield

Shape134 Face mask with protective shield

Shape135 Non-splash resistant disposable gown

Shape136 Splash resistant disposable gown

Shape137 Protective eye glasses/goggles

Shape138 Supplied air respirator

Shape139 Respirator with cartridge/HEPA filters

If selected, ask: Please specify the type of cartridge/filter:

Shape140 Other

If selected, ask: Please specify the type of protection:

General Survey Module H: Communication

If respondent is an emergency responder, go to next module.

Now I would like to ask you a few questions about the communication you may have received regarding the incident.

If respondent is aged 13-17, continue to Question H1. Otherwise, go to Question H2.

If respondent is an adult, skip to Question H2. If respondent is aged 13-17, read: How did you hear about the incident?

Go to Question H3

Fill in the table below. Ask H2 i and only check the box next to the type of information the respondent received first. Then follow-up with H2 ii for the information the respondent received first. Continue to H2 iii and check all boxes that apply and follow-up with H2 iv for each type of follow-up information the respondent received.

Source of Information	How did you first receive information or instructions about the incident? Check only one box.	Was the information you first received timely? Was it accurate? Write yes, no, or DK (for don’t know) in the appropriate box.		How did you receive follow-up information or instructions about the incident? Check all that apply.	Was the follow-up information you received from [source] timely? Was it accurate? Write yes, no, or DK (for don’t know) in the appropriate box.
Source of Information		Timely	Accurate		Timely	Accurate
Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor/ coworker
Website
Reverse 911 call
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify:

In the future, what are the best ways for your local authorities or the health department to reach you with information regarding a chemical incident? Check all that apply:

Shape146 TV

Shape147 Radio

Shape148 Newspaper

Shape149 Website

Shape150 Phone call

Shape151 Text message on a cell phone

Shape152 Email

Shape153 Community meeting

Shape156 Other (Please specify):

General Survey Module I: Needs

If respondent is an emergency responder, go to next module.

As a result of the incident, do you need any of the following…

Read all choices to the respondent.

Medicines or supplies Yes No
Medical care Yes No
Water Yes No
Food Yes No
Shelter Yes No
Utilities Yes No
Anything else Yes No

If yes, please specify:

If needs are identified in Question I1, obtain details on exactly what is needed so this can be provided to the state health department. Otherwise, continue to the next module.

General Survey Module J: Exposure of Other People Present

Were there any other individuals present with you in the highlighted area of the map during the incident? Show highlighted area of the map.

Shape160 Yes

Shape162 No  Go to next module

In order to accurately evaluate the impact of the incident, we are trying to interview as many people who were in the area as possible. Fill in the following table with the information given for Question J2 a-c.
1. Can you tell me the names of everyone else who was present with you during the incident?
2. Which are children, and what are their ages?
3. Can you tell me the phone number and e-mail address of the people who do not live with you?

Name	Age (if child)	Phone	E-mail

General Survey Module K: Pets

Did you have any pets or assistance animals that were in the highlighted area of the map during the incident? Show highlighted area of the map.

Shape165 Yes

Shape167 No  Go to next module

How many of your pets or assistance animals were in the highlighted area during the incident?

________ Pets/Assistance animals

We will ask further questions about your pet(s) or assistance animal(s) later in the survey.

Continue to next module

General Survey Module L: Demographic and Contact Information

Now, I have some general questions about you.

Do you consider yourself to be Hispanic or Latino?

Shape171 Yes

Shape172 No

What race do you consider yourself to be?

Check all that apply:

Shape173 Black or African American

Shape174 White

Shape175 Asian

Shape176 American Indian or Alaska Native

Shape177 Native Hawaiian or Other Pacific Islander

What is the highest level of education you completed?

Shape178 Grade 8 or Less

Shape179 Some High School

Shape180 High School Graduate or Equivalent

Shape181 Some University/College

Shape182 Technical or Trade School

Shape183 Junior or Community College

Shape184 University/College Graduate

Shape185 Graduate School or Higher

If necessary, ask. Otherwise, check appropriate box. Are you male or female?

Shape186 Male

Shape187 Female

If respondent is registered in the Rapid Response Registry (RRR), read and verify RRR information. If changes are needed, enter them into Questions L5-L9, then go to Question L10.

If not in RRR, ask Questions L5-L9, and then continue on to Question L10.

What is your date of birth?

____/____/______
MM DD YYYY

What is your current address?

Street Apt

City State __ __ Zip Code:

What is the best telephone number to reach you? Please specify if this is a cellular phone, house phone, or work phone.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Shape189 Cell

Shape190 House

Shape191 Work

Are there any more telephone numbers where you can be reached?

If yes, collect all other numbers and specify whether cell, house, or work number.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Shape192 Cell

Shape193 House

Shape194 Work

( __ __ __ ) __ __ __ ‑ __ __ __ __

Shape195 Cell

Shape196 House

Shape197 Work

Do you have an email address where you can be reached?

Shape198 Yes

Shape200 No Go to Question L10

What is your email address?

We may want to interview you again in the future to check up on your health. Keeping in mind that people move, we would like to get a little more information to help us locate you in the future. In case you move to another residence, could we have the names and contact information of three people who live outside of your household and who would always know how to find you?

Shape202 Yes  Complete the table provided

Shape204 No  Go to next module

	Person 1	Person 2	Person 3
First and Last Name
Address
Phone Number (including area code)
Email Address
Relationship to you (parent, child, sibling, other relative, friend, other)

General Survey Module M: Supplemental Questions

[Insert event specific questions requested by the local health department here].

General Survey Module N: Conclusion Statements

Is there anything else you want to tell us related to the [chemical] incident?

If Exposure of Other People Present Module did not identify children under the age of 13 that were present, go to Question N3. If children under the age of 13 were identified, read: I would now like to ask you some questions regarding any children you have under the age of 13 that were with you when you were in the highlighted areas of the map.

Refer to Module J to recall child’s name and then go to the Child Survey Section

If the Pets Module did not identify that the respondent had a pet or assistance animal in the highlighted area of the map during the incident, go to the “Closing Statement.” If pets or assistance animals were identified, read: I would now like to ask you some questions regarding any pets or assistance animals you have that were in the highlighted areas of the map.

Go to the Pet Survey Section

Closing Statement:

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.

Child’s Name: ________________________________________ Participant ID _________

SECTION II: ACE CHILD SURVEY

Child Survey Module A: Location/Exposure

Who was [Child’s name] with when he/she was in the highlighted area on the map between [incident date/time] and [end date/time]? Show area on map.

Shape212 Respondent

Record name and Participant ID of person with same exposure:

____________________________________________________  Go to Question A3

Shape214 Someone else who has been interviewed

Record name and Participant ID of person with same exposure:

____________________________________________________  Go to Question A3

Shape216 Someone who has not been interviewed

Record name of person with same exposure:

____________________________________________________

I would like to know about each place [Child’s name] went within the highlighted area on the map between [incident date] at [time] and [end date/time] so that I can construct a timeline and understand what happened when he/she was exposed. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location.

	Location 1:	Location 2:	Location 3:
What is the address where [Child’s name] (first/next) was during the incident? Probe for as much location information as possible. Then, continue to b. Do not ask about all locations first. Collect all information about one location before continuing to the next.
How long was [Child’s name] in this location? Record whether in minutes or hours.
Was he/she inside or outside while they were there? If outside, skip questions d, e, and f.	In Out	In Out	In Out
If inside, were there any open windows while he/she was there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If inside, was there any ventilation, such as an [air conditioner/heater] running, while he/she was there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If respondent said “yes” for d or e, circle “no” for f and skip to next question. Otherwise, if inside, ask: did he/she shelter in place, meaning staying inside, with doors and windows closed and all ventilation systems turned off? If yes, ask respondent: Please describe what he/she did to shelter in place.	Yes No Unsure	Yes No Unsure	Yes No Unsure
Was [Child’s name] in a [smoke cloud/dust/fog] while he/she was there?	Yes No Unsure	Yes No Unsure	Yes No Unsure

Did [Child’s name] evacuate from the highlighted area on the map?

Shape217 Yes

Shape219 No Go to Question A5

At approximately what time did he/she evacuate?

____:_____ Shape220 AM Shape221 PM

Hour Min

How did he/she evacuate?

Shape222 Ambulance

Shape223 Privately-owned vehicle

Shape224 Bus

Shape225 Other (Please specify):

Is there any additional information that you think we should know about [Child’s name]’s exposure?

Shape226 Yes Record the information on the lines provided below

Shape228 No Go to Question A7

Was [Child’s name] decontaminated, meaning their clothing was removed or their body was washed?

Shape229 Yes

Shape231 No Go to next module

How was [Child’s name] decontaminated? Read all answer choices aloud to the respondent and check all that apply.

Shape232 Clothing Removal

Shape233 Water

Shape234 Soap and Water

Shape235 Other (Please specify):

Where was he/she decontaminated? If respondent needs clarification, specify that this question is asking for a geographic location, not a place on the child’s body.

At approximately what time was [Child’s name] decontaminated?

____:_____ Shape236 AM Shape237 PM

Hour Min

Child Survey Module B: Health Status

Now I would like to ask you some questions about any symptoms [Child’s name] may have experienced after the incident.

Within 24 hours of the incident, did [Child’s name] have any symptoms of an illness?

Shape240 Yes

Shape242 No Go to next module

I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom.

	Did [Child’s name] experience [Symptom] within 24- hours of the incident? If yes, go to ii. If no, repeat i for next symptom.		Was [Child’s name] experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.		Was [Child’s name]’s [Symptom] worse after the incident? Continue to iv (if listed); otherwise; repeat i for next symptom.		Is [Child’s name] still experiencing [Symptom]? Repeat i for next symptom.
Symptom	Yes	No	Yes	No	Yes	No	Yes	No
Irritation/pain/ burning of eyes
Increased tearing
Blurred vision/double vision
Runny nose
Burning nose or throat
Burning lungs
Increased salivation
Ringing of the ears
Difficulty swallowing
Odor on breath (Gasoline or other, specify)
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Difficulty concentrating
Weakness of arms
Weakness of legs
Muscle twitching
Tremors in arms or legs
Loss of balance
Breathing slow
Breathing fast
Difficulty breathing/feeling out-of-breath
Coughing
Increased congestion or phlegm
Wheezing in chest
Slow heart rate/pulse
Fast heart rate/pulse
Chest tightness or pain/angina
Blue or gray coloring of ends of fingers/toes or lips
Nausea
Non-bloody vomiting
Non-bloody diarrhea
Bloody vomiting
Blood in stool/diarrhea
Abdominal pain
Fecal incontinence or inability to control bowel movements
Irritation, pain, or burning of skin
Skin rash
Skin blisters
Sweating
Cool or pale skin
Skin discoloration
Anxiety
Agitation/irritability
Fatigue/tiredness
Difficulty sleeping
Feeling depressed
Generalized weakness
Diffuse muscle aches and pains
Hallucinations
Urinary incontinence or dribbling pee
Inability to urinate or pee
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

Child Survey Module C: Fire/Explosion

Was [Child’s name] injured as a result of the fire or explosion?

Shape245 Yes

Shape247 No Go to next module

I’m going to ask you some questions about injuries that can happen as a result of a fire or explosion. For some of these injuries, I’m going to ask you where on your child’s body they were located. Fill out the table below. Repeat C2 i-ii for one injury and check the boxes that apply before asking about the next injury.

	Did [Child’s name] experience [Injury] within 24-hours after the fire or explosion? If yes, go to C2 ii. If no, repeat C2 i for next injury.		If Yes, where on his/her body was it located? Repeat C2 i for next injury.
Injury	Yes	No
Abrasion/scrape
Broken bone/fracture
Bruise
Cut
Dislocation
Sprain or strain
Burn
Crush injury
Severe bleeding
Ear drum puncture
Hearing loss
Ringing in ears
Whiplash
Concussion
Bowel perforation
Eye injury
Any other injuries? If yes, what was it? If applicable, specify where on his/her body was it located? Record below.
1.
2.

Child Survey Module D: Medical care

Did [Child’s name] receive medical care or evaluation because of the incident?

Shape251 Yes  Go to Question D3

Shape252 No

Why didn’t you seek medical care for [Child’s name]?

Shape253 Did not have symptoms

Shape254 Symptoms were not bad enough

Shape255 Don’t like to go to the doctor

Shape256 Didn’t want to take time

Shape257 Worried about who would pay for the medical visit

Shape258 Worried about losing job

Shape259 Other (Please specify): ______________________________________________________

Shape260 Unsure

For those individuals who did not seek medical care for the child, go to the next module.

Was [Child’s name] provided with care by an EMT or paramedic?

Shape262 Yes

Shape264 No  Go to Question D5

On what date was he/she provided care by an EMT or paramedic?

____/____/______

MM DD YYYY

Was [Child’s name] provided with care at a hospital?

Shape265 Yes

Shape267 No  Go to Question D15

On what date was [Child’s name] first provided care at a hospital? If he/she had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the child first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

What is the name of the hospital(s)?

How did [Child’s name] get to the hospital? If the child had more than one hospital visit, tell the respondent that you are referring to the child’s first visit.

Shape268 EMS/Ambulance

Shape269 Driven by relative, friend, or acquaintance

Shape270 Other (Please specify):

Was [Child’s name] treated only in the emergency department or was he/she admitted to the hospital?

Shape272 Treated in an emergency department (Outpatient)  Go to Question D15

Shape273 Admitted (Hospitalized)

How many nights was he/she hospitalized, including any nights in an intensive care unit (ICU)?

________Nights

Was he/she placed in an Intensive Care Unit or ICU?

Shape274 Yes

Shape276 No  Go to Question D15

How many nights was he/she in the ICU?

________ Nights

Was he/she on a ventilator?

Shape277 Yes

Shape279 No  Go to Question D15

How many nights was he/she on a ventilator?

________ Nights

Besides at a hospital or by an EMT or paramedic, was [Child’s name] seen by a doctor or other medical professional?

Shape280 Yes

Shape282 No  Go to Question D17

Read i-iv to the respondent and record information in the table below.

On what dates was [Child’s name] provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

Was [Child’s name] prescribed any new medicines when he/she was examined after the incident?

Shape283 Yes

Shape285 No  Go to Question D19

What is the name of the medicine or medicines [Child’s name] was prescribed after being examined? If respondent does not know the name of the medication, ask: What is the medicine for?

Please tell me if any of the following describe why you sought medical care for [Child’s name]. Read questions a-c to the respondent and circle the appropriate answer(s).
1. Were you given instructions to seek medical care for

[Child’s name]? Yes No Unsure

[Child’s name] experienced health problems or

symptoms within 24 hours of the incident? Yes No Unsure

You were worried about possible health problems

for [Child’s name] associated with the incident? Yes No Unsure

To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment (he/she) received because of the incident?

Shape287 Yes  Review the medical records release form with the respondent and collect their signature

Shape288 No

Child Survey Module F: Medical History

Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used.

Prior to the incident, have you ever been told by a doctor or other health care provider that [Child’s name] has any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
Allergies?	Yes (Please specify)___________________ No Unsure
Asthma?	Yes No Unsure
Diabetes?	Yes No Unsure
High blood pressure?	Yes No Unsure
Physical disability that hinders mobility?	Yes (Please specify)___________________ No Unsure
Psychological condition such as depression?	Yes (Please specify) __________________ No Unsure
Cancer?	Yes (Please specify) _________________ No Unsure
Neurological conditions such as cerebral palsy?	Yes No Unsure
Developmental conditions such as ADHD/ADD or autism?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _________________ No Unsure

Prior to the incident, was [Child’s name] taking any medicines? This includes medicines prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives.

Shape289 Yes

Shape291 No Go to next module

Shape293 Don’t Know Go to next module

What medicines was [Child’s name] taking? If respondent does not know the name of the medication, ask: What was the medicine for?

Child Survey Module L: Demographic and Contact Information

Now, I have some general questions about [Child’s name].

Do you consider [Child’s name] to be Hispanic or Latino?

Shape296 Yes

Shape297 No

What race do you consider him/her to be?

Check all that apply:

Shape298 Black or African American

Shape299 White

Shape300 Asian

Shape301 American Indian or Alaska Native

Shape302 Native Hawaiian or Other Pacific Islander

If necessary, ask. Otherwise, check appropriate box. Is [Child’s name] male or female?

Shape303 Male

Shape304 Female

What is [Child’s name]’s date of birth?

____/____/______

MM DD YYYY

Child Survey Module M: Supplemental Questions

[Insert event specific questions requested by the local health department here].

Child Survey Module N: Concluding Instructions

Shape309

If there are more children under age 13, get a new child survey and ask about next child.

Shape310

If there are no more children under age 13, return to the General Survey Module N: Conclusion Statements and go to Question N3.

Shape311 SECTION III: ACE PET SURVEY

Now I am going to ask you about each of your pets or assistance animals and their experience with the incident. From now on, I will refer to both pets and assistance animals as pets.

If more than 1 pet, read: I will ask you about Pet 1 first, then Pet 2, etc. You can decide which pet you want to tell me about first.

Pet # ____

What type of animal is your pet?

Shape313 Dog Shape314 Fish  Go to Question 3

Shape315 Cat Shape316 Other (Please specify):

Shape317 Bird

What is your pet’s name? ___________________________

What is your pet’s breed or type? ___________________________

If pet is dog or cat, continue with Question 4. If fish, go to Question 7. If bird or other, go to Question 6.

What is your pet’s hair length? Read all choices to the respondent and check appropriate box.

Shape319 Short

Shape320 Medium

Shape321 Long

Shape322 Hairless

If pet is cat, go to Question 6.

How much does your dog weigh? Would you say…Read all choices except “Don’t Know” to respondent and check appropriate box.

Shape324 Less than 20 pounds,

Shape325 Between 20-50 pounds

Shape326 More than 50 pounds

Shape327 Don’t Know

How old is your pet? If older than 12 months, report in years. Check the appropriate box.

_________ Shape328 Months Shape329 Years

Where was your pet located at the time of the incident?

Shape331 At the respondent’s home  Go to Question 10

Shape333 In a vehicle  Go to Question 8

Shape335 Someplace else  Go to Question 9

Shape337 Don’t Know  Go to Question 10

On [Day of incident], how long was your pet in a vehicle in the area highlighted on the map? Report in minutes or hours. Check the appropriate box.

_________ Shape338 Minutes Shape339 Hours

What is the address where the pet was located at the time of the incident? If don’t know, ask: Do you know what street or intersection it was on or near? Probe for as much location information as possible.

If pet was in a vehicle while in the area highlighted on the map, go to Question 11.

How long was your pet inside for the [Fill hour] hours after the incident? Would you say… Read all choices except “Don’t Know” to the respondent and check appropriate box.

Shape341 91–100% of the time,

Shape342 51–90% of the time,

Shape343 11–50% of the time, or

Shape344 0–10% of the time?

Shape345 Don’t know

In the 24-hour period following the incident, did your pet… Read all choices to the respondent and circle appropriate response.

a. Get injured? Yes No Don’t Know

b. Become ill? Yes No Don’t Know

c. Go missing? Yes No Don’t Know

d. Die? Yes No Don’t Know

e. If missing and not dead:
Was your pet found? Yes No Don’t Know

If respondent answered “yes” to any part of 11, read: Please tell me what happened to your pet. Otherwise, go to question 13.

Was your pet examined by a veterinarian as a result of the incident?

Shape346 Yes

Shape348 No  Go to Question 16

Shape350 Don’t Know  Go to Question 16

What is the name of the veterinarian who examined the pet, or the name of the veterinarian’s practice?

If respondent is under age 18, go to Question 16.

To improve future responses, we try to study all exposures, including animal exposures, as thoroughly as possible. Are you willing to let us get a copy of your pet’s veterinary records for the medical treatment your pet received because of the incident?

Shape352 Yes

Shape353 No

Did you evacuate your pet?

Shape354 Yes

Shape356 No  Go to Question 18

Where did you take your pet?

Either ask about next pet or, if all pets have been discussed, do the following based on respondent’s answer to Question 15:

If “yes” to 15, review the veterinary records release form with the respondent, collect their signature, and then go to the “Closing Statement” in the General Survey module.
If “no” to 15 or the question was skipped because the respondent was aged 13-17, go to the “Closing Statement” in the General Survey Module.

Why didn’t you evacuate your pet?

Either ask about next pet or, if all pets have been discussed, do the following based on respondent’s answer to Question 15:

If “yes” to 15, review the veterinary records release form with the respondent, collect their signature, and then go to the “Closing Statement” in the General Survey module.
If “no” to 15 or the question was skipped because the respondent was aged 13-17, go to the “Closing Statement” in the General Survey Module.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	RSmartis
File Modified	0000-00-00
File Created	2021-01-23