General Fire guidelines

Fire-Related Injuries Treated in Hospital Emergency Rooms
Questionnaire # ________ (1-4)
Q.1

Please enter Task Number
[REQUIRE ANSWER]
_________________________________________________________________________________

Q.2

(5-17)

Instructions: If the injured person is under 18 years of age, ask for the parent or guardian.
Introduction
Hello, May I speak with ____________?
I'm calling for the Consumer Product Safety Commission. I understand that (you / your child) recently
received an injury caused by a fire. We are presently updating information we collect from hospital
emergency departments on fires and would like to ask you some questions about the fire.
Be prepared to answer questions with the following information:
- that the identity will be kept confidential
- that the purpose of the study is to prevent future incidents and injuries
- there is a particular interest in what caused the fire

[REQUIRE ANSWER]
(18)

q1
q2

Agreed
Refused

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 4]

Q.3

Are you familiar with how this incident happened?
[REQUIRE ANSWER]
(19)

q1
q2

Yes
No

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 9]

OMB Control Number 3041-0029

Q.4

Is there someone else who is more familiar with the details of the incident?
[REQUIRE ANSWER]
(20)

q1
q2

Yes
No

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 41]

Q.5

Record name and phone number if different
________________________________________________________________________________

Q.6

(21-70)

May I speak with him/her?
[REQUIRE ANSWER]
(71)

q1
q2

Yes
No

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 2]

Q.7

When would be a good time to contact him/her?
[REQUIRE ANSWER]
________________________________________________________________________________

Q.8

Continue with interview?
[REQUIRE ANSWER]
(97)

q1
q2

Yes
No

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 41]

OMB Control Number 3041-0029

(72-96)

Q.9

Who is the respondent?
[REQUIRE ANSWER]
(98)

q1
q2
q3

Injured person
Parent or guardian of injured person
Other (specify in next window)

[S - IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 11]

Q.10

Specify relationship of respondent to injured person
[REQUIRE ANSWER]
_______________________________________________________________________________

Q.11

(99-123)

Our information shows that _________ is a (male/female) who was age _________ at the
time of the incident. Is this correct?
[REQUIRE ANSWER]
(124)

q1
q2
q3

Yes
No
Don't Know

[S - IF THE ANSWER IS NOT 2, THEN SKIP TO QUESTION 13]

Q.12

What is the correct age and sex?

[REQUIRE ANSWER]
______________________________________________________________________________

Q.13

(125-134)

Please describe your/ name of victim's injury or injuries in the fire.
[REQUIRE ANSWER]
______________________________________________________________________________

OMB Control Number 3041-0029

(135-284)

Q.14

Interviewer: did the injuries include burns?
[REQUIRE ANSWER]
(285)

q1
q2

Yes
No

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 16]

Q.15

How did the doctor characterize the burns you/ victim's name received in the fire?
[Probe: Did the doctor specify the percent of body surface burned?
Did the doctor specify whether the burns were first, second, or third degree burns?
Did the doctor specify whether the burns were partial thickness or full thickness burns?]
[REQUIRE ANSWER]
______________________________________________________________________________

Q.16

(286-535)

We are particularly interested in learning the causes of the fires that involved smoke
inhalation, unintended flames or smoke, or unintended spread of flames or smoke. Did
any of these happen?
[REQUIRE ANSWER]
(536)

q1
q2
Q.17

Yes
Not a fire

Can you briefly describe the incident that resulted in your/ name of victim's injury?
[REQUIRE ANSWER]
_____________________________________________________________________________
[D - IF THE ANSWER TO QUESTION 16 IS 2, THEN SKIP TO QUESTION 41]

Q.18

Did you see the fire start?
[REQUIRE ANSWER]
(1737)

q1
q2

Yes
No

OMB Control Number 3041-0029

(537-1736)

Q.19

Can you describe what item or equipment provided the heat that started the fire, for
example, a stove, heater, cigarette, cigarette lighter, match, fireplace, open bonfire,etc?
[REQUIRE ANSWER]
(1738)

q1
q2

Yes
No / Unknown

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 26]

Q.20

Describe the item or equipment.
[ If the incident described involved a friendly fire (a fire ignited for an intended purpose such as
cooking, heating, burning trash, etc.) probe for the equipment/item involved in unintended fire
spread rather than the product (match/lighter) used to light the friendly fire. For example, list
the gas grill rather than the match used to light the grill.]
Record as close to verbatim as possible, write unknown if they do not provide any details about
the heat source.
[REQUIRE ANSWER]
____________________________________________________________________________

Q.21

(1739-1888)

Interviewer: Was the source described a manufactured product?
(manufactured product: stove, toaster, electric cord, etc.
non-manufactured product: bonfire, etc.)
[REQUIRE ANSWER]
(1889)

q1
q2

Yes, manufactured product
No / Don't know

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 26]

Q.22

Can you tell me the manufacturer's or brand name? I can wait while you go get it.
[REQUIRE ANSWER]
(1890)

q1
q2

Yes, specify in next window
Don't know

[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 24]

OMB Control Number 3041-0029

Q.23

Specify
[REQUIRE ANSWER]
____________________________________________________________________________

Q.24

(1891-1965)

Do you have any reason to believe the fire started (or spread) because the heat source
didn't work as intended?
[REQUIRE ANSWER]
(1966)

q1
q2
q3
q4

Yes, describe in next window
No
Other, specify in next window
Don't know

[S - IF THE ANSWER IS 2 OR 4, THEN SKIP TO QUESTION 26]

Q.25

Please describe the reason
[REQUIRE ANSWER]
____________________________________________________________________________

Q.26

(1967-2166)

Was the fire started by a child playing with a heat source? For example: a lighter, match,
heater, etc.?
[REQUIRE ANSWER]
(2167)

q1
q2
q3

Yes
No
Don't know

[S - IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 28]

Q.27

How old was the child at the time of the fire?
Enter years and months for the age of the child or "don't know" if age is unknown. If more than
one child was present and the respondent doesn't know which one started the fire, enter the age
of the older child.
[REQUIRE ANSWER]
____________________________________________________________________________
OMB Control Number 3041-0029

(2168-2177)

Q.28

Now I would like to ask about where the incident occurred. Did it occur in, or involve, a
structure or building of some sort?
[REQUIRE ANSWER]
(2178)

q1
q2
q3
q4

Yes
No (specify location in next window)
Other (specify in next window)
Unknown

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 30]
[S - IF THE ANSWER IS 4, THEN SKIP TO QUESTION 40]

Q.29

Specify
[REQUIRE ANSWER]
____________________________________________________________________________

(2179-2203)

[A - IF THE ANSWER TO QUESTION 28 IS 2 OR 3, THEN SKIP TO QUESTION 39]

Q.30

What kind of structure was it, for example: single family residence, apartment building,
dormitory, hotel, etc.?
[REQUIRE ANSWER]
(2204)

q1
q2
q3
q4
q5
q6
q7
q8

1 or 2 family home, w/wo garage, inc mobile home
multi-family structure, inc condo , apt, town home
Other residential- dorm, group house, hotel
Other commercial/industrial building
Camper, recreational vehicle
Shed, detached garage
Other (specify in next window)
Don't know

[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 34]
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 36]
[S - IF THE ANSWER IS 4, THEN SKIP TO QUESTION 32]
[S - IF THE ANSWER IS 5 OR 6 OR 8, THEN SKIP TO QUESTION 39]
[S - IF THE ANSWER IS 7, THEN SKIP TO QUESTION 33]

Q.31

Specify other residential type
[REQUIRE ANSWER]
____________________________________________________________________________
[D - IF THE ANSWER TO QUESTION 30 IS 3, THEN SKIP TO QUESTION 36]
OMB Control Number 3041-0029

(2205-2229)

Q.32

Specify other commercial/industrial
i.e. office, store, manufacturing plant, etc.
[REQUIRE ANSWER]
____________________________________________________________________________

(2230-2254)

[D - IF THE ANSWER TO QUESTION 30 IS 4, THEN SKIP TO QUESTION 36]

Q.33

Specify other
[REQUIRE ANSWER]
____________________________________________________________________________

(2255-2279)

[D - IF THE ANSWER TO QUESTION 30 IS 7, THEN SKIP TO QUESTION 36]

Q.34

Was it a mobile structure such as a mobile home or manufactured home?
[REQUIRE ANSWER]
(2280)

q1
q2
q3

Yes (specify type in next window)
No
Don't know

[S - IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 36]

Q.35

Specify type
[REQUIRE ANSWER]
____________________________________________________________________________

Q.36

(2281-2305)

Did the structure have an installed smoke alarm (detector) at the time of the fire?
[REQUIRE ANSWER]
(2306)

q1
q2
q3

Yes
No
Don't know

[S - IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 39]

OMB Control Number 3041-0029

Q.37

Did a smoke alarm sound/signal during the fire?
[REQUIRE ANSWER]
(2307)

q1
q2
q3
q4

Yes
No
Other (specify in next window)
Don't know

[S - IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 39]

Q.38

Specify
[REQUIRE ANSWER]
____________________________________________________________________________

Q.39

(2308-2332)

Did the fire department respond to this incident?
[REQUIRE ANSWER]
(2333)

q1
q2
q3
Q.40

Yes
No
Don't Know

Is there anything else you would like to tell me about the fire or about the injuries that
occurred?
[REQUIRE ANSWER]
____________________________________________________________________________

(2334-2833)

Thank you for your time. Your information has been very helpful.

Q.41

Interviewer: What is the date this interview was completed? (MM/DD/YY)
____________________________________________________________________________

OMB Control Number 3041-0029

(2834-2843)