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

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Shape2

Appendix 2: General Survey

















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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:


  1. 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.


  1. 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)

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:


  1. 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.






  1. How long were you in this location? Record whether in minutes or hours.




  1. Were you inside or outside while you were there? If outside, skip questions d, e, and f.

In Out

In Out

In Out

  1. If inside, were there any open windows while you were there?

Yes No Unsure

Yes No Unsure

Yes No Unsure

  1. 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

  1. 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

  1. Did you smell an odor? If no or unsure skip questions h and i.

Yes No Unsure

Yes No Unsure

Yes No Unsure

  1. Can you please describe the odor?




  1. Would you describe the odor as light, moderate or severe?

Light Moderate Severe

Light Moderate Severe

Light Moderate Severe

  1. Were you in a [smoke cloud/dust/fog] while you were there?

Yes No Unsure

Yes No Unsure

Yes No Unsure




  1. Did you evacuate from the highlighted area on the map?

Shape9 Yes

Shape10

Shape11 No Go to Question A5


  1. At approximately what time did you evacuate?

____:_____ Shape12 AM Shape13 PM

Hour Min


  1. How did you evacuate?

Shape14 Ambulance

Shape15 Privately-owned vehicle

Shape16 Bus

Shape17 Other (Please specify):



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

Shape18 Yes Record the information on the lines provided below

Shape19

Shape20 No Continue to Question A7


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

Shape21 Yes

Shape22

Shape23 No Go to next module


  1. 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):


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


  1. 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.


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

Shape30 Yes

Shape31

Shape32 No Go to next module


  1. 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.



  1. Did you experience [Symptom] within 24-hours of the incident? If yes, go to ii. If no, repeat i for next symptom.

  1. Were you experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.

  1. Was your [Symptom] worse after the incident? Continue to iv (if listed); otherwise, repeat i for next symptom.

  1. 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

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

Shape33 Yes

Shape34

Shape35 No Go to next module


  1. 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.


  1. 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.

  1. 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


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

Shape38

Shape39 Yes Go to Question D3

Shape40 No


  1. 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

Shape49


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


  1. Were you provided with care by an EMT or paramedic?

Shape50 Yes

Shape51

Shape52 No Go to Question D5


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

____/____/______

MM DD YYYY


  1. Were you provided with care at a hospital?

Shape53 Yes

Shape54

Shape55 No Go to Question D15


  1. 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.


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

MM DD YYYY

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

MM DD YYYY

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

MM DD YYYY


  1. What is the name of the hospital(s)?


  1. 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):


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

Shape60

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

Shape62 Admitted (Hospitalized)


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

________ Nights


  1. Were you placed in an Intensive Care Unit or ICU?

Shape63 Yes

Shape64

Shape65 No Go to Question D15


  1. How many nights were you in the ICU?

________ Nights


  1. Were you on a ventilator?

Shape66 Yes

Shape67

Shape68 No Go to Question D15


  1. How many nights were you on a ventilator?

________ Nights


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

Shape69 Yes

Shape70

Shape71 No Go to Question D17

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


  1. On what dates were you provided care by a doctor or other medical professional? (mm/dd/yyyy)

  1. What is the name of the doctor or other medical professional?

  1. What service did this doctor or medical professional provide?

  1. What is the address of the office?


















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

Shape72 Yes

Shape73

Shape74 No Go to Question D19


  1. 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?


  1. 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

Shape75


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.


  1. 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?

Shape76

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.


  1. Are you currently employed?

Shape81

Shape82 Yes Go to Question E3

Shape83 No


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

Shape84 Yes

Shape85

Shape86 No Go to Question E4


  1. 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

  1. What (is/was) the name of the company you (work/worked) for?



  1. What (does/did) this company make or do?



  1. What (is/was) your job title?



  1. (Does/Did) this job include working with or around any chemicals? If no or unsure, go to f.

Yes No Unsure

Yes No Unsure

  1. If yes, what chemicals (do/did) you work with or around?



  1. Did you have any other jobs since [12 months ago]?

      1. 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.

      1. 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.


  1. 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


  1. Allergies?

Yes (Please specify) ______________________

No

Unsure

  1. Asthma?

Yes

No

Unsure

  1. Diabetes?

Yes

No

Unsure

  1. High blood pressure?

Yes

No

Unsure

  1. Chronic obstructive pulmonary disease (COPD) or emphysema?

Yes

No

Unsure

  1. Heart Disease?

Yes

No

Unsure

  1. Physical disability that hinders mobility?

Yes (Please specify)_______________________

No

Unsure

  1. Psychological condition such as anxiety, depression or dependence disorder?

Yes (Please specify) ______________________

No

Unsure

  1. Cancer?

Yes (Please specify) _____________________

No

Unsure

  1. Immune disorders such as lupus, rheumatoid arthritis, or HIV?

Yes

No

Unsure

  1. Neurological conditions such as Parkinson’s disease or multiple sclerosis?

Yes

No

Unsure

  1. Any other medical conditions?

Yes (Please specify) _____________________

No

Unsure


  1. 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

Shape90

Shape91 No Go to Question F4

Shape92

Shape93 Don’t Know Go to Question F4


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


  1. Do you currently smoke cigarettes, cigars, or pipes?

Shape94

Shape95 Yes Go to instruction box before Question F7

Shape96 No


  1. Have you smoked regularly in the past?

Shape97 Yes

Shape98

Shape99 No Go to instruction box before Question F7


  1. 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

Shape104


If respondent is male, go to next module


  1. Are you currently pregnant?

Shape105 Yes

Shape106 No

Shape107 Don’t Know


  1. Are you currently breastfeeding?

Shape108 Yes

Shape109 No


General Survey Module G: Emergency Response


  1. 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

Shape117

Shape118 Not a responder Go to next module


  1. What specifically was your role during the response?


Shape119

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



  1. 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




Shape129

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


  1. 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

Shape143


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.

Shape144


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


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


Shape145


Go to Question H3

  1. 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

  1. How did you first receive information or instructions about the incident? Check only one box.


  1. Was the information you first received timely? Was it accurate? Write yes, no, or DK (for don’t know) in the appropriate box.

  1. How did you receive follow-up information or instructions about the incident? Check all that apply.

  1. 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:







  1. 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

Shape157


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


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

Read all choices to the respondent.

    1. Medicines or supplies Yes No

    2. Medical care Yes No

    3. Water Yes No

    4. Food Yes No

    5. Shelter Yes No

    6. Utilities Yes No

    7. Anything else Yes No

If yes, please specify:


  1. 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


  1. 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

Shape161

Shape162 No Go to next module


  1. 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


  1. 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

Shape166

Shape167 No Go to next module


  1. 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.

Shape168


Continue to next module




General Survey Module L: Demographic and Contact Information


Now, I have some general questions about you.


  1. Do you consider yourself to be Hispanic or Latino?

Shape171 Yes

Shape172 No


  1. 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


  1. 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


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

Shape186 Male

Shape187 Female

Shape188


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.


  1. What is your date of birth?

____/____/______
MM DD YYYY


  1. What is your current address?

Street Apt

City State __ __ Zip Code:


  1. 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


  1. 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


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

Shape198 Yes

Shape199

Shape200 No Go to Question L10


What is your email address?




  1. 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?

Shape201

Shape202 Yes Complete the table provided

Shape203

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





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



General Survey Module N: Conclusion Statements


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


  1. 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.

Shape209

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


  1. 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.


Shape210

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 _________


Shape211



SECTION II: ACE CHILD SURVEY


Child Survey Module A: Location/Exposure



  1. 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

Shape213

Record name and Participant ID of person with same exposure:

____________________________________________________ Go to Question A3

Shape214 Someone else who has been interviewed

Shape215

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:

____________________________________________________


  1. 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:


  1. 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.






  1. How long was [Child’s name] in this location? Record whether in minutes or hours.




  1. Was he/she inside or outside while they were there? If outside, skip questions d, e, and f.

In Out

In Out

In Out

  1. If inside, were there any open windows while he/she was there?

Yes No Unsure

Yes No Unsure

Yes No Unsure

  1. 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

  1. 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

  1. Was [Child’s name] in a [smoke cloud/dust/fog] while he/she was there?

Yes No Unsure

Yes No Unsure

Yes No Unsure


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

Shape217 Yes

Shape218

Shape219 No Go to Question A5



  1. At approximately what time did he/she evacuate?

____:_____ Shape220 AM Shape221 PM

Hour Min


  1. How did he/she evacuate?

Shape222 Ambulance

Shape223 Privately-owned vehicle

Shape224 Bus

Shape225 Other (Please specify):

  1. 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

Shape227

Shape228 No Go to Question A7


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

Shape229 Yes

Shape230

Shape231 No Go to next module


  1. 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):


  1. 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.

  1. 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.


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

Shape240 Yes

Shape241

Shape242 No Go to next module


  1. 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.



  1. Did [Child’s name] experience [Symptom] within 24- hours of the incident? If yes, go to ii. If no, repeat i for next symptom.

  1. Was

[Child’s name] experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.

  1. Was

[Child’s name]’s

[Symptom] worse after the incident? Continue to iv (if listed); otherwise; repeat i for next symptom.

  1. 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


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

Shape245 Yes

Shape246

Shape247 No Go to next module


  1. 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.


  1. 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.

  1. 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


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

Shape250

Shape251 Yes Go to Question D3

Shape252 No


  1. 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

Shape261


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


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

Shape262 Yes

Shape263

Shape264 No Go to Question D5


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

____/____/______

MM DD YYYY


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

Shape265 Yes

Shape266

Shape267 No Go to Question D15


  1. 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.


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

MM DD YYYY

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

MM DD YYYY

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

MM DD YYYY


  1. What is the name of the hospital(s)?


  1. 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):


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

Shape271

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

Shape273 Admitted (Hospitalized)


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

________Nights


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

Shape274 Yes

Shape275

Shape276 No Go to Question D15


  1. How many nights was he/she in the ICU?

________ Nights


  1. Was he/she on a ventilator?

Shape277 Yes

Shape278

Shape279 No Go to Question D15


  1. How many nights was he/she on a ventilator?

________ Nights


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

Shape280 Yes

Shape281

Shape282 No Go to Question D17



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


  1. On what dates was [Child’s name] provided care by a doctor or other medical professional? (mm/dd/yyyy)

  1. What is the name of the doctor or medical professional?

  1. What service did this doctor or medical professional provide?

  1. What is the address of the office?


















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

Shape283 Yes

Shape284

Shape285 No Go to Question D19


  1. 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?


  1. 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

    1. [Child’s name] experienced health problems or

symptoms within 24 hours of the incident? Yes No Unsure

    1. You were worried about possible health problems

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


  1. 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?

Shape286

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.


  1. 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


  1. Allergies?

Yes (Please specify)___________________

No

Unsure

  1. Asthma?

Yes

No

Unsure

  1. Diabetes?

Yes

No

Unsure

  1. High blood pressure?

Yes

No

Unsure

  1. Physical disability that hinders mobility?

Yes (Please specify)___________________

No

Unsure

  1. Psychological condition such as depression?

Yes (Please specify) __________________

No

Unsure

  1. Cancer?

Yes (Please specify) _________________

No

Unsure

  1. Neurological conditions such as cerebral palsy?

Yes

No

Unsure

  1. Developmental conditions such as ADHD/ADD or autism?

Yes

No

Unsure

  1. Any other medical conditions?

Yes (Please specify) _________________

No

Unsure

  1. 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

Shape290

Shape291 No Go to next module

Shape292

Shape293 Don’t Know Go to next module


  1. 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].


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

Shape296 Yes

Shape297 No



  1. 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


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

Shape303 Male

Shape304 Female


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

____/____/______

MM DD YYYY


Child Survey Module M: Supplemental Questions



  1. [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 # ____


  1. What type of animal is your pet?

Shape312

Shape313 Dog Shape314 Fish Go to Question 3

Shape315 Cat Shape316 Other (Please specify):

Shape317 Bird


  1. What is your pet’s name? ___________________________


  1. What is your pet’s breed or type? ___________________________

Shape318


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


  1. 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

Shape323


If pet is cat, go to Question 6.


  1. 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


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

_________ Shape328 Months Shape329 Years



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

Shape330

Shape331 At the respondent’s home Go to Question 10

Shape332

Shape333 In a vehicle Go to Question 8

Shape334

Shape335 Someplace else Go to Question 9

Shape336

Shape337 Don’t Know Go to Question 10


  1. 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


  1. 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.

Shape340


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


  1. 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


  1. 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


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



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

Shape346 Yes

Shape347

Shape348 No Go to Question 16

Shape349

Shape350 Don’t Know Go to Question 16


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

Shape351


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


  1. 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


  1. Did you evacuate your pet?

Shape354 Yes

Shape355

Shape356 No Go to Question 18


  1. Where did you take your pet?

Shape357


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.


  1. Why didn’t you evacuate your pet?

Shape358


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.

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