Form 0920-18LQ Fire Fighter Follow-back Survey revised

Attachment C Fire Fighter Follow-back Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Exp. Date xx/xx/20xx

Fire Fighter Injuries/Illnesses/Exposures

Questionnaire # ___________________

This is the Fire Fighter Injuries/Illnesses/Exposures Survey

Tasknum – Enter task number

__________________________

Instruct_1. Bold type indicates what should be read to the respondent. Instructions for the interviewer or frequently asked questions will be prefaced by “Interviewer:” and are written in non-bold type.

Interviewer: Please do not read choices to yes/no questions or give examples unless explicitly instructed to do so. Do not read the “Refused” or “Don’t Know” choices. If the respondent is unsure, read applicable interviewer notes if available. Otherwise, say, “Please give me the answer you think is best.”

Instruct_2. Interviewer: Prior to calling the respondent, please review their case and complete the following.

Name - Interviewer: Complete before dialing.

What is your name? (Interviewer's first and last name)

___________________________________________________________________________________

tx_date - Interviewer: Complete before dialing.

Enter the month, day, year of treatment.

Month (MM) ____

Day (DD) ____

Year (YY) ____

Public reporting burden of this collection of information is estimated to average 30minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Interview Introduction

Hello. My name is (interviewer name). I am calling for the National Institute for Occupational Safety and Health, also known as NIOSH. In the last few weeks, you should have received a letter from the Consumer Product Safety Commission explaining a research study on injuries involving fire fighters. As the letter indicated, we are gathering information on injuries among career and volunteer fire fighters who were injured while performing fire fighting duties. This study has no connection to workers’ compensation or disability claims. You were chosen for this study from emergency department records. I understand that on ___/____/____ you were treated in the emergency department for an incident that occurred at work.

1) Is this correct?

1. Yes

2. No

*Programming note: If 1 = a, SKIP to Consent

*Programming note: If 1 = b, GOTO 2

2) Were you recently treated on a different day in a hospital emergency department?

1. Yes

2. No

*Programming note: If 2 = a, GOTO to 3

*Programming note: If 2 = b, END interview

3) What day was that?

Month (MM) ____

Day (DD) ____

Year (YY) ____

*Programming note: If date is within 21 days of recorded date, GOTO Consent

*Programming note: If date is greater than 21 days from recorded date, END interview

Consent - The letter you received explained how we will protect your privacy. I am required to tell you four things that were mentioned in this letter:

1. Taking part in this study involves a small risk to your privacy, but we take many steps to prevent that risk.

2. There is no direct benefit or reimbursement for taking part in this study.

3. Your answers to our questions will be kept private to the extent allowed by law. Your name, address, nor anything else that could identify you will never be associated with the information you give and will not be in any records held by the NIOSH.

4. If you have questions about the study or you feel you were harmed, you may call Suzanne Marsh, CDC project officer, at 304-285-6009. For questions about your rights, your privacy, or harm to you , contact the Chair of the NIOSH Institutional Review Board in the Human Research Protection Program at 513-533-8591.

I would like to ask you some questions about your incident. Your participation is particularly important to us because you represent a number of fire fighters who were not selected for interview. This interview takes about 30 minutes. The information that you provide will be used for prevention purposes only and does not have any bearing on the worker’s compensation process or benefits. This study is voluntary. You may choose to be in the study or not. You do not have to answer any questions you do not want to. You can end the call at any time without any consequences.

4) Would you please help us by answering some questions?

1. Yes

2. No

*Programming note: If 4 = a, SKIP to Instruct_3

*Programming note: If 4 = b, GOTO 5

5) I assure you that everything you tell us will be kept private and will only be used to study how to prevent injuries to fire fighters. Your participation is very important and will benefit fire fighters. Would you please reconsider helping us?

1. Yes

2. No

*Programming note: If 5 = a, SKIP to Instruct_3

*Programming note: If 5 = b, GOTO 5

6) I understand that this may be a bad time. May I call back another time?

1. Yes

2. No

*Programming note: If 6 = a, note preferred time and call back later

*Programming note: If 6 = b, END interview

Screen - Assess whether respondent was working as a fire fighter/EMS worker at the time of injury/illness/exposure

1. At the time of the incident that sent you to the emergency department, were you assigned as...? (Read categories.)

1. Both a fire fighter and an EMT or paramedic (GOTO 2)

2. A fire fighter only (GOTO 2)

3. An EMT or paramedic only

4. Neither a fire fighter nor an EMT or paramedic

*Programming note: If 1 = c or d, END interview

2. At the time of the incident, what type of fire fighter were you? (Read categories.)

1. A volunteer fire fighter

2. A part-paid or on-call fire fighter (GOTO 3)

3. A career fire fighter (GOTO 3)

4. DON’T KNOW

*Programming note: If 2 = a, SKIP to Instruct_3

*Programming note: If 2 = d, END interview

3. What type of department was it? (Read categories.)

1. A Federal department

2. A state department

3. A county department

4. A city department

5. A private or industrial department

6. DON’T KNOW

Instruct_3. This first series of questions asks about the incident that caused you to seek care in the emergency department on [date]. These questions refer to the emergency department as the ED.

Injury/illness/exposure (IIE) description

1. Throughout the rest of the interview, we want to use one word to refer to why you went to the ED. Which of these words works best: injury, illness or exposure?

Interviewer: If the respondent hesitates or says don’t know, say the following: There is no right or wrong answer. Choose the word that best describes why you went to the ED.

1. Injury

2. Illness

3. Exposure

4. REFUSED

*Programming note: the answer from 1 will only be used as a fill-in for the remainder of the survey [IIE] but will not be used for data analysis.

*Programming note: If 1 = d, END interview

*Programming note: If 1 = a, GOTO 2

*Programming note: If 1 = b, SKIP to 3

*Programming note: If 1 = c, SKIP to 4

2. [If 1 = a] What was your injury?

_____________________________________________________________________________

*Programming note: If 1 = a, SKIP to 5

2. [If 1 = b] What was your illness?

_____________________________________________________________________________

*Programming note: If 1 = b, SKIP to 5

2. [If 1 = c] What were you exposed to?

_____________________________________________________________________________

5. Please describe in your own words why you went to the ED.

Interviewer: If respondent hesitates, ask the following: “What happened that sent you to the ED?”

Interviewer: If respondent suggests that there was more than one reason, ask the respondent to describe the reason that was related to their fire fighter duties.

Interviewer: If respondent suggests that there was more than one reason related to their job, ask the respondent to describe the reason they felt was more severe.

Interviewer: If not included in the description, use the following questions as prompts:

1. What were you doing when your injury or exposure happened?

2. Were your activities part of your job duties?

3. Where were you? In a building? Outside of a building? On a road?

4. Thinking about equipment other than personal protective equipment, what equipment were you using?

_____________________________________________________________________________

*Programming note: If 1 = a or c, GOTO 6

*Programming note: If 1 = b, SKIP to 9

6. What part of your body was most affected by your [IIE]?

_____________________________________________________________________________

6. Were any other parts of your body affected?

1. Yes (GOTO 8)

2. No

3. DON’T KNOW

*Programming note: If 7 = b or c, SKIP to 9

6. [If 7 = a] Please describe the other parts of your body affected by your [IIE].

_____________________________________________________________________________

6. What treatment did you receive in the ED for your [IIE]?

_____________________________________________________________________________

6. Now I’m going to read you a list of sources people use to pay medical bills. Please tell me which source you THINK you will use to pay your ED bill.

Interviewer: If respondent suggests that they have two or more payers, ask “Which of these do you think will pay the larger part of the bill?”

1. Worker’s Compensation

2. Health insurance

3. Yourself, also called out-of-pocket

4. Another source

5. None

6. DON’T KNOW

*Programming note: If 10 = a, b, c, e, or f, SKIP to Instruct_5

11. Please tell me the source you think you will use to pay your ED bill.

_____________________________________________________________________________

Instruct_5. I’d now like to ask you some questions about your specific duties at the time of your [IIE] and additional details about the incident that you were involved in.

*Programming note: If 2 (Screen) = a, SKIP to 3

Incident characteristics

1. [If 2 (Screen) = b or c] In hours, how long was your scheduled shift?

_____________________________________________________________________________

2. About how many hours of your shift had you worked when your [IIE] occurred?

_____________________________________________________________________________

3. Approximately what time did your [IIE] occur? (Unknown = 99)

Interviewer: If the respondent does not indicate, ask whether the time is AM or PM.

Time _____________

AM/PM _____________

4. Were you on a call when your [IIE] occurred?

Interviewer: If the respondent asks whether responding to or returning from a call is included, please say the following: A call includes responding or returning from a call and time on scene.

1. Yes (GOTO 5)

2. No

*Programming note: If 4 = b, SKIP to 27

5. [If 4 = a] What type of call were you on when your [IIE] occurred? Was it a…? (Read categories.)

1. Working fire including structural, vehicle, or brush

2. Medical

3. Motor vehicle, that did not involve a working fire

4. Alarm, including fire or CO, that did not involve a working fire

5. Public assistance

6. Another type (GOTO 6)

*Programming note: If 5 = a, SKIP to 7

*Programming note: If 5 = b, c, d, or e, SKIP to 9

6. [If 5 = f] Please describe the call.

_____________________________________________________________________________

*Programming note: If 5 = f, SKIP to 9

7. [If 5 = a] What type of working fire was it? (Read categories.)

1. Structure

2. Wildland, brush, grass, or wildland urban interface

3. Vehicle

4. Another outside fire (e.g., trash)

5. Some other type of fire (GOTO 8)

*Programming note: If 7 = a, b, c, or d, SKIP to 9

8. [If 7 = e] Please describe the type of fire.

_____________________________________________________________________________

9. I am going to read you a list of locations. As I read each one, please tell me whether you were in that location when your [IIE] occurred.

	Yes (1)	No (2)	Programming note
a) At the station			GOTO 9b
b) Getting in or out of a vehicle			If (9a = 1) AND (9b = 1), SKIP to 12 If (9a = 2) AND (9b = 1), SKIP to 9d If (9a = 1 or 2) AND (9b = 2), GOTO 9c
c) In a vehicle			If (9a = 1) AND (9c = 1), SKIP to 12 If (9a = 1) AND (9b = 2) AND (9c = 2), SKIP to 10 If (9a = 2) AND (9c = 1 or 2), GOTO 9d
d) On scene			If ((9b = 1) OR (9c = 1)) AND (9d = 1 or 2), SKIP to 12 If ((9b = 2) AND (9c = 2)) AND (9d = 1) AND (5 = a) SKIP to 25 If ((9b = 2) AND (9c = 2)) AND (9d = 1) AND (5 NE a), SKIP to Instruct_6 If (9a = 2) AND (9b = 1 or 2) AND (9d = 2), GOTO 9e
e) In some other place			If 9e = 1, SKIP to 11
f) DON’T KNOW			If 9f = 1, SKIP to Instruct_6

10. [If (9a = 1) AND (9b = 2) AND (9c = 2)] Please tell me what you were doing.

_____________________________________________________________________________

*Programming note: If (9a = 1) AND (9b = 2) AND (9c = 2), SKIP to Instruct_6

11. [If 9e = 1] Please tell me where you were when your [IIE] occurred.

_____________________________________________________________________________

*Programming note: If (9b = 1) AND (9e = 1), GOTO 12

*Programming note: If (9b = 2) AND (9e = 1), SKIP to Instruct_6

12. [If 9b = 1 OR 9c = 1] What type of vehicle was it? (Read categories.)

1. A fire apparatus or fire vehicle

2. An ambulance or medic unit

3. A personal vehicle

4. Another type (GOTO 13)

*Programming note: If 12 = a, SKIP to 14

*Programming note: If (12 = b) AND (9b = 1), SKIP to Instruct_6

*Programming note: If (12 = b) AND (9b = 2), SKIP to 21

*Programming note: If (12 = c) AND (9b = 1), SKIP to Instruct_6

*Programming note: If (12 = c) AND (9b = 2), SKIP to 20

13. [If 12 = d] Please describe the vehicle.

_____________________________________________________________________________

*Programming note: If (12 = d) AND (9b = 1), SKIP to Instruct_6

*Programming note: If (12 = d) AND (9b = 2), SKIP to 20

14. [If 12 = a] What type of fire apparatus was it? (Read categories.)

1. An engine

2. A heavy rescue

3. A tanker or tender truck

4. A ladder truck

5. A brush truck

6. A utility vehicle

7. A command vehicle

8. Another type (GOTO 15)

*Programming note: If (14 = a, b, c, d, e, f, or g) AND (9b = 1), SKIP to Instruct_6

*Programming note: If (14 = a, b, c, d, e, f, or g) AND (9b = 2), SKIP to 16

15. [If 14 = h] Please tell me what type of fire apparatus it was.

_____________________________________________________________________________

*Programming note: If (14 = h) AND (9b = 1), SKIP to Instruct_6

*Programming note: (f (14 = h) AND (9b = 2), GOTO 16

16. [If 12 = a] What was your location in the fire apparatus when your [IIE] occurred? Were you in the…? (Read categories.)

1. Driver seat

2. Front officer seat

3. Jumpseat

4. Tiller

5. Another location (GOTO 17)

*Programming note: If 16 = a, b, c, or d, SKIP to 21

17. [If 16 = e] Please describe your location.

_____________________________________________________________________________

*Programming note: If 12 = a, SKIP to 21

18. [If 12 = b] What was your location in the ambulance or medic unit when your [IIE] occurred? Were you in the…? (Read categories.)

1. Driver seat

2. Front passenger seat

3. Patient compartment

4. Another location (GOTO 21)

*Programming note: If 18 = a, b, or c, SKIP to 21

19. [If 18 = d] Please describe your location.

_____________________________________________________________________________

*Programming note: If 12 = b, SKIP to 21

20. [If 12 = c or d] Were you driving the vehicle when your [IIE] occurred?

1. Yes

2. No

21. [If 9c = 1] What were you doing at the time your [IIE] occurred? Were you….? (Read categories.)

1. Responding or going to a call

2. Returning from a call (GOTO 22)

3. Doing something else

*Programming note: If 21 = a, SKIP to 24

*Programming note: If 21 = c, SKIP to 23

22. [If 21 = b] Were you assisting in transporting a patient from a call?

1. Yes

2. No

*Programming note: If 21 = b, SKIP to 24

23. [If 21 = c] Please tell me what you were doing.

_____________________________________________________________________________

24. At the time of your [IIE], were lights or sirens being used by the vehicle you were in?

1. Yes

2. No

*Programming note: If 9c = 1, SKIP to Instruct_6

25. [If 5 = a AND 9d = 1] I am going to read you a list of activities that you may have been doing when your [IIE] occurred. Please stop me when I read the activity you were doing. (Read categories.)

1. Search and rescue

2. Forcible entry

3. Ventilation

4. Fire attack

5. Salvage and overhaul

6. Driver operator, chauffeur, or engineer

7. Incident management

8. Another activity (GOTO 26)

*Programming note: If 25 NE h, SKIP to Instruct_6

26. [If 25 = h] Please describe the activity you were doing when your [IIE] occurred.

_____________________________________________________________________________

*Programming note: If 5 = a AND 9d = 1, SKIP to Instruct_6

27. [If 4 = b] What activity were you performing at the time of your [IIE]? Was it….? (Read categories.)

Interviewer: If any part of respondent’s answer includes training, choose answer c.

1. Station activity (GOTO 28)

2. Physical fitness activity at the station

3. Training

4. Another activity

*Programming note: If 27 = b, SKIP to 29

*Programming note: If 27 = c, SKIP to 30

*Programming note: If 27 = d, SKIP to 31

28. [If 27 = a] Please describe the station activity you were doing.

_____________________________________________________________________________

*Programming note: If 27 = a, SKIP to Instruct_6

29. [If 27 = b] Please describe the physical fitness activity you were doing.

_____________________________________________________________________________

*Programming note: If 27 = b, SKIP to Instruct_6

30. [If 27 = c] Please describe the training that you were participating in.

_____________________________________________________________________________

*Programming note: If 27 = c, SKIP to Instruct_6

31. [If 27 = d] Please describe the activity that you were doing.

_____________________________________________________________________________

Instruct_6. I’m now going to ask you a series of questions related to the incident that led to your [IIE]. Not all of the scenarios will apply to your situation.

Event-specific characteristics

Overexertion and strains

1. Your [IIE] may have been caused by your own physical effort, awkward body posture, or repetitive motion. These injuries could occur while working in tight quarters or while moving a heavy object. Was your [IIE] caused by your own physical effort, body posture, or repetitive motion?

1. Yes (GOTO 2)

2. No (SKIP to 1 in Exposure to heat, smoke, or toxic agents)

3. DON’T KNOW (SKIP to 1 in Exposure to heat, smoke, or toxic agents)

2. I am going to read you a list of activities. As I read each one, please tell me whether or not you were doing the activity when your [IIE] occurred.

	Yes	No
a) Going up or down stairs
b) Getting into or out of a vehicle
c) Turning a corner or negotiating a turn
d) Twisting
e) Working above shoulder level
f) Working below waist level
g) Walking on a rough or uneven surface such as an uneven floor or a steep bank
h) Rushing to complete a task
i) Using an awkward posture or movement because of the space you were in
j) Walking or stepping on a surface that was not dry
k) Transferring, carrying, or lifting a person
l) Transferring, carrying, or lifting equipment

*Programming note: If 2 = j only or with any other response, GOTO 3

*Programming note: If (2 NE j) AND (2 = k only or with any other response), SKIP to 5

*Programming note: If (2 NE j) AND (2 NE k) AND (2 = l only or with any other response), SKIP to 6

*Programming note: If (2 NE j) AND (2 NE k) AND (2 NE l), SKIP to 9

3. [If 2 = j only or with any other response] You told me the surface you were walking on was not dry. What was on that surface? (Read categories.)

1. Water

2. Ice

3. Snow

4. Grease

5. Another substance (GOTO 4)

6. DON’T KNOW

*Programming note: If (3 NE e) AND (2 = k only or with any other response), SKIP to 5

*Programming note: If (3 NE e) AND (2 NE k) AND (2 = l only or with any other response), SKIP to 6

*Programming note: If (3 NE e) AND (2 NE k) AND (2 NE l), SKIP to 9

4. [If 3 = e] Please describe what was on the surface when your [IIE] occurred.

_____________________________________________________________________________

*Programming note: If (2 NE k) AND (2 = l only or with any other response), SKIP to 6

*Programming note: If (2 NE k) AND (2 NE l), SKIP to 9

5. [If 2 = k only or with any other response] You told me you were transferring, carrying, or lifting a person at the time of your [IIE]. Was that person overweight or obese?

1. Yes

2. No

3. DON’T KNOW

6. Were there other persons assisting you with the transfer, carry, or lift?

1. Yes (GOTO 7)

2. No

3. DON’T KNOW

*Programming note: If (2 = l) AND (7 = b or c), SKIP to 8

*Programming note: If (2 NE l) AND (7 = b or c), SKIP to 9

7. [If 6 = a] How many were assisting you?

NumPersons __________

*Programming note: If 2 NE l, SKIP to 9

8. [If 2 = l only or with any other response] You told me you were transferring, carrying, or lifting equipment at the time of your [IIE]. Please describe the equipment.

_____________________________________________________________________________

9. Prior to this [IIE], did you have a sprain, strain, or repetitive motion injury to the same part of your body?

1. Yes

2. No

3. DON’T KNOW

Exposure to heat, smoke, or toxic agents

1. Fire fighters are often exposed to heat, flames, and smoke. Fire fighters may also be exposed to other toxic agents including carbon-monoxide, poison ivy, or harmful gases. Were you exposed to heat, smoke, or other toxic agents when your [IIE] occurred?

1. Yes (GOTO Instruct_7)

2. No (SKIP to 1 in Exposure to a potentially harmful substance)

3. DON’T KNOW (SKIP to 1 in Exposure to a potentially harmful substance)

Instruct_7. I’m now going to ask you some additional questions about your exposure.

2. I am going to read you a list of items you may have been exposed to when your [IIE] occurred. As I read each one, please tell me whether or not you were exposed to that item. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Heat
b) Flames
c) Carbon monoxide
d) Poison ivy
e) Some other item

*Programming note: If 2 = e only or with any other response, GOTO 3

* Programming note: If (2 NE e) AND 7 (Incident characteristics) = d, e, or blank, SKIP to 1 in Exposure to a potentially harmful substance

* Programming note: If (2 NE e) AND 7 (Incident characteristics) = a, b, or c, SKIP to Instruct_8

3. [If 2 = e only or with any other response] Please describe what you were exposed to.

_____________________________________________________________________________

* Programming note: If 7 (Incident characteristics) = d, e, or blank, SKIP to 1 in Exposure to a potentially harmful substance

Instruct_8. I’m now going to ask you some additional questions about the fire incident that you were involved in when you were exposed.

*Programming note: If 7 (Incident characteristics) = a, GOTO 4

*Programming note: If 7 (Incident characteristics) = b, SKIP to 12

*Programming note: If 7 (Incident characteristics) = c, SKIP to 22

4. [If 7 (Incident characteristics) = a] Earlier you told me you were on the scene of a structure fire. What type of structure was it? (Read categories.)

1. A 1 or 2 family dwelling, including mobile home

2. A multi-family dwelling

3. Non-residential or commercial (GOTO 5)

4. Other

5. DON’T KNOW

*Programming note: If 4 = a, b, or, e, SKIP to 7

*Programming note: If 4 = d, SKIP to 7

5. [If 4 = c] Please describe the non-residential or commercial structure.

_____________________________________________________________________________

*Programming note: If 4 = c, SKIP to 7

6. [If 4 = d] Please describe the type of structure.

_____________________________________________________________________________

7. Where were you at the time of your [IIE]? Were you….? (Read categories.)

1. Inside the structure

2. Outside the structure

3. DON’T KNOW

8. Were there civilians in the structure that was on fire?

1. Yes

2. No

3. DON’T KNOW

9. Was there an incident commander on scene when your [IIE] occurred?

1. Yes

2. No

3. DON’T KNOW

10. I am going to read you a list of factors that may have contributed to your IIE. As I read each one, please tell me whether or not the factor contributed to your [IIE]. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Collapsing or falling object
b) Changes to the direction or flow path of the fire
c) Lost, caught, trapped, or confined
d) Another factor

*Programming note: if 10 = d only or with any other response, GOTO 11

*Programming note: if 10 NE d, SKIP to 1 in Exposure to a potentially harmful substance

11. [If 10 = d or with any other response] Please describe any other factors that contributed to your [IIE].

_____________________________________________________________________________

*Programming note: if 7(Incident characteristics) = a, SKIP to 1 in Exposure to a potentially harmful substance

12. [If 7 (Incident characteristics) = b] Earlier you told me you were on scene of a wildland, brush, or grass fire. What type of area did the fire occur in? (Read categories.)

1. An area without residents, largely still wild and undisturbed

2. Rural, farm area, or heavily timbered area

3. In a city, large town, or suburb

4. Other (GOTO 13)

5. DON’T KNOW

*Programming note: if 12 = a, b, c, or e, SKIP to 14

13. [If 12 = d] Please describe the area where the fire occurred.

_____________________________________________________________________________

14. Was the fire a prescribed burn?

1. Yes

2. No

3. Don’t Know

15. What response activity were you doing when your [IIE] occurred? Were you doing…? (Read categories.)

1. Initial attack

2. Suppression

3. Mop-up

4. Another activity (GOTO 16)

5. DON’T KNOW

*Programming note: If 15 = a, b, c, or e, SKIP to 17

16. [If 16 = d] Please describe your activity.

_____________________________________________________________________________

17. What type of wildland fire fighter crew were you on at the time of your [IIE]? Were you on…? (Read categories.)

1. A handcrew

2. An engine crew

3. Jumper or Rapeller

4. Management oroverhead

5. Another type (GOTO 18)

6. Not part of a crew

7. DON’T KNOW

*Programming note: If 17 = a, b, c, d, f, or g, SKIP to 19

18. [If 17 = e] Please describe your crew type.

_____________________________________________________________________________

19. Was there an incident commander on scene when your [IIE] occurred?

1. Yes

2. No

3. DON’T KNOW

20. I am going to read you a list of factors that may have contributed to your IIE. As I read each one, please tell me whether or not the factor contributed to your [IIE]. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Changes to the direction or flow path of the fire
b) Falling object, including a snag or rock
c) Equipment such as chainsaw, hand tools, or drop torch
d) All-terrain vehicle
e) Other motor vehicle
f) Another factor

*Programming note: If 20= f only or with any other response, GOTO 21

*Programming note: If 20 NE f, SKIP to 1 in Exposure to a potentially harmful substance

21. [If 20 = f only or with any other response] Please describe any other factors that contributed to your [IIE].

_____________________________________________________________________________

*Programming note: If 7 (Incident characteristics) = b, SKIP to 1 in Exposure to a potentially harmful substance

22. [If 7 (Incident characteristics) = c] Earlier you told me you were on scene of a vehicle fire. What type of vehicle was on fire? (Read categories.)

1. An automobile or passenger vehicle including a pick-up truck

2. A commercial vehicle including a bus or tractor trailer

3. Another type (GOTO 23)

4. DON’T KNOW

*Programming note: If 22 = a, b, or d, SKIP to 24

23. [If 23 = c] What type of vehicle was it?

_____________________________________________________________________________

24. Was there an incident commander on scene when your [IIE] occurred?

1. Yes

2. No

3. DON’T KNOW

Exposure to a potentially harmful substance

1. Fire fighters may be exposed to other potentially hazardous substances not related to a fire scene. These hazardous substances may include drugs or bodily fluid either from direct contact or indirect contact with a patient or other person. Were you exposed to a potentially hazardous substance?

1. Yes (GOTO Instruct_9)

2. No (SKIP to 1 in Falls/Slips/Trips)

3. DON’T KNOW (SKIP to 1 in Falls/Slips/Trips)

Instruct_9. I’m now going to ask you some additional questions about your exposure to a potentially harmful substance. Some of these questions may duplicate previous questions but I must ask them as written.

2. [If 1 = a] I am going to read you a list of ways you may have been exposed. As I read each one, please tell me whether your exposure occurred in that way. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Being stuck by a needle
b) Being coughed or spit on
c) Inhaling a potentially hazardous substance
d) Bite
e) Another way (GOTO 3)

*Programming note: if 2 = a, SKIP to 8

*Programming note: if 2 = b, c, or d, SKIP to 4

3. [If 2 = e] Please describe how the exposure occurred.

_____________________________________________________________________________

4. I am going to read you a list of substances you may have been exposed to. As I read each item, please tell me whether you were exposed to that substance. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Blood
b) Respiratory secretions such as spit
c) Urine, feces, or other biological waste
d) Another substance, including chemicals

*Programming note: if 4 = a, b, c, or e, SKIP to 6

5. [If 4 = d] Please describe the other potentially harmful substance that you were exposed to.

_____________________________________________________________________________

6. I am going to read you a list of possible parts of your body that may have been exposed. As I read each body part, please tell me whether or not that part of your body was exposed. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Eyes
b) Mouth or nose
c) Arms and hands
d) Some other part

*Programming note: If 6 = d only or with any other response, GOTO 7

*Programming note: If 6 NE d, SKIP to 8

7. [If 6 = d only or with any other response] Please describe the parts of your body that were exposed.

_____________________________________________________________________________

8. I am going to read you a list of activities. Please tell me whether or not you were doing any of these activities when your [IIE] occurred.

	Yes	No
a) Patient care
b) Moving a patient
c) Restraining a patient

Falls/Slips/Trips

1. Did you fall off of or through something, like a weak floor or a hole, when your [IIE] occurred?

1. Yes

2. No (GOTO 2)

3. DON’T KNOW (GOTO 2)

*Programming note: If 1 = a, SKIP to 3

2. Did your [IIE] involve a slip, trip, stumble, or loss of balance?

1. Yes (GOTO 3)

2. No (SKIP to 1 in Transportation)

3. DON’T KNOW (SKIP to 1 in Transportation)

*Programming note: If (1 = a or 2 = a) AND (1 (Overexertion and strains) = a), SKIP to 11

3. I am now going to read you a list of activities. Please tell me whether or not you were doing any of these activities when your [IIE] occurred.

	Yes	No
a) Going up or down stairs, steps, or curb
b) Getting into or out of a vehicle
c) Turning a corner or negotiating a turn
d) Walking on a rough or uneven surface such as an uneven floor or a steep bank
e) Rushing to complete a task
f) Walking or stepping on a surface that was not dry
g) Transferring, carrying, or lifting a person
h) Transferring, carrying, or lifting equipment
i) Pushing, pulling, or dragging something

*Programming note: If 3 = f only or with any other response, GOTO 4

*Programming note: If (3 NE f) AND (3 = g only or with any other response), SKIP to 6

*Programming note: If (3 NE f) AND (3 NE g) AND (3 = h only or with any other response), SKIP to 9

*Programming note: If (3 NE f) AND (3 NE g) AND (3 NE h) AND (3 = i), SKIP to 10

*Programming note: If (3 NE f) AND (3 NE g) AND (3 NE h) AND (3 NE i), SKIP to 11

4. [If 3 = f only or with any other response] You told me that the surface you were walking on was not dry. What was on that surface? (Read categories.)

1. Water

2. Ice

3. Snow

4. Grease

5. Another substance (GOTO 5)

6. DON’T KNOW

*Programming note: If (4 NE e) AND (3 = g only or with any other response), SKIP to 6

*Programming note: If (4 NE e) AND (3 NE g) AND (3 = h only or with any other response), SKIP to 9

*Programming note: If (3 NE e) AND (3 NE g) AND (3 NE h) AND (3 = i), SKIP to 10

*Programming note: If (3 NE e) AND (3 NE g) AND (3 NE h) AND (3 NE i), SKIP to 11

5. [If 4 = e] Please describe what was on the surface when your [IIE] occurred.

_____________________________________________________________________________

*Programming note: If 3 = g only or with any other response, SKIP to 6

*Programming note: If (3 NE g) AND (3 = h only or with any other response), SKIP to 9

*Programming note: If (3 NE g) AND (3 NE h) AND (3 = i), SKIP to 10

*Programming note: If (3 NE g) AND (3 NE h) AND (3 NE i), SKIP to 11

6. [If 3 = g only or with any other response] You told me that you were transferring, carrying, or lifting a person at the time of your [IIE]. Was that person overweight or obese?

1. Yes

2. No

3. DON’T KNOW

7. Were there other persons assisting you with the transfer, carry, or lift?

1. Yes (GOTO 8)

2. No

3. DON’T KNOW

*Programming note: If (3 = h) AND (7 = b or c), SKIP to 9

*Programming note: If (3 NE h) AND (3 = i) AND (7 = b or c), SKIP to 10

*Programming note: If (3 NE h) AND (3 NE i) AND (7 = b or c), SKIP to 11

8. [If 7 = a] How many were assisting you?

NumPersons __________

*Programming note: If (3 NE h) AND (3 = i), SKIP to 10

*Programming note: If (3 NE h) AND (3 NE i), SKIP to 11

9. [If 3 = h only or with any other response] You told me that you were transferring, carrying, or lifting equipment at the time of your [IIE]. Please describe that equipment.

_____________________________________________________________________________

10. [If 3 = i only or with any other response] You told me that you were pushing, pulling, or dragging something. Please describe what it was.

_____________________________________________________________________________

11. Was there an obstacle in your way when your [IIE] occurred?

1. Yes (GOTO 12)

2. No

3. DON’T KNOW

*Programming note: If (5 (Incident Characteristics) = a) AND (11 = b or c), SKIP to 13

*Programming note: If (5 (Incident Characteristics) NE a) AND (11 = b or c), SKIP to 1 in Transportation

12. [If 11 = a] Please describe the obstacle.

_____________________________________________________________________________

*Programming note: If 5 (Incident Characteristics) = a, GOTO 13

*Programming note: If 5 (Incident Characteristics) NE a, SKIP to 1 in Transportation

13. Was your vision obscured by smoke?

1. Yes

2. No

3. Don’t Know

Transportation

1. A motor vehicle incident includes incidents where the vehicle that you were in swerved, stopped suddenly, or overturned. These incidents may involve a collision where the vehicle you were in was struck by another vehicle or struck an object, person, or animal. Motor vehicle incidents also include situations where a person is outside of a vehicle and is struck. Did your [IIE] involve a motor vehicle incident?

1. Yes (GOTO Instruct_10)

2. No (SKIP to 1 in Violence)

3. DON’T KNOW (SKIP to 1 in Violence)

Instruct_10. I’m now going to ask you some additional questions about your motor vehicle incident. Some of these questions may duplicate previous questions but I must ask them as written.

2. [If 1 = a] I am going to read you a list of events. Please stop me when you hear the option that best describes the event that contributed to your [IIE]. (Read categories.)

	Yes	No	DON’T KNOW
a) The vehicle you were in struck another vehicle
b) The vehicle you were in was struck by another vehicle
c) The vehicle you were in struck a fixed object
d) The vehicle you were in rolled over
e) The vehicle you were in swerved or stopped suddenly (*Programming note: If 2 = a – e, SKIP 2f)
f) You were not in a vehicle and you were struck
g) Something else (GOTO 3)

*Programming note: If 2 = a or b, SKIP to 4

*Programming note: If 2 = c, SKIP to 8

*Programming note: If 2 = d or e, SKIP to 9

*Programming note: If 2 = f, SKIP to 14

3. [If 2 = g] Please describe the incident.

_____________________________________________________________________________

*Programming note: If 9c (Incident characteristics) = 1, SKIP to 10

*Programming note: If 9c (Incident characteristics) NE 1, SKIP to 15

4. [If 2 = a or b] What type of collision was it? (Read categories.)

1. Head-on

2. Broadside

3. T-boned

4. Rear-end

5. DON’T KNOW

5. At the time of the collision, what was the vehicle you were in doing? (Read categories.)

1. It was moving

2. It was stopped in traffic

3. It was parked on the side of the road

4. It was parked somewhere else

5. It was doing something else (GOTO 6)

6. DON’T KNOW

*Programming note: If 5 = a, SKIP to 7

*Programming note: If 5 = b, c, d, or f, SKIP to 10

6. [If 5 = e] Please describe the vehicle’s actions.

_____________________________________________________________________________

7. I am going to read you options that your vehicle may have been doing at the time of the collision. As I read each option, please tell me whether it describes the activity of your vehicle. (Read categories.)

	Yes	No	DON’T KNOW
a) Moving straight ahead
b) Turning right or left
c) Backing
d) Changing lanes, overtaking, or passing
e) Making a U-turn
f) Negotiating a curve

*Programming note: If 2 = a or b, SKIP to 10

8. [If 2 = c] What did the vehicle strike?

_____________________________________________________________________________

*Programming note: If 2 = c, SKIP to 10

9. [If 2 = d or e] What caused the vehicle to roll over, swerve, or stop suddenly?

_____________________________________________________________________________

10. Was anyone in the vehicle serving as incident commander when your [IIE] occurred?

1. Yes

2. No

3. DON’T KNOW

11. Were you wearing a seatbelt when your [IIE] occurred?

1. Yes

2. No (GOTO 12)

*Programming note: If 11 = a, SKIP to 21

12. I am going to read you a list of reasons why a fire fighter may not wear a seatbelt. As I read each one, please tell me whether it describes why you were not wearing a seatbelt. (Read categories.)

	Yes	No	DON’T KNOW
a) You did not have time to put it on
b) You could not buckle it due to bunker gear
c) A seatbelt was not available
d) You were in a position not designed for occupants
e) You were providing patient care
f) Another reason

*Programming note: If 12 = a, b, c, d, e, or g, SKIP to 21

13. [If 12 = f] Please tell me why you weren’t wearing a seatbelt.

_____________________________________________________________________________

*Programming note: If 2 = a, b, c, d, e, or g, SKIP to 21

14. [If 2 = f] Please tell me what you were doing when you were struck by a vehicle.

_____________________________________________________________________________

15. At the time you were struck, were you on the shoulder of the road?

1. Yes

2. No (GOTO 16)

3. DON’T KNOW

*Programming note: If 15 = a or c, SKIP to 18

16. Were you on the roadway?

1. Yes

2. No (GOTO 17)

3. DON’T KNOW

*Programming note: If 16 = a or c, SKIP to 18

17. Please tell me where you were when you were struck.

_____________________________________________________________________________

18. Was an incident commander on scene when your [IIE] occurred?

4. Yes

5. No

6. DON’T KNOW

19. I am going to read you a list of traffic control strategies. As I read each one, please tell me whether it was being used prior to your [IIE].

	Yes	No	DON’T KNOW
a) A temporary traffic control pattern
b) Cones
c) A temporary barrier or barricade
d) Flares, warning lights, or warning devices
e) Signboards
f) Another strategy for traffic control (GOTO 17)

*Programming note: If 16 = a, b, c, d, or e, SKIP to 21

20. Please tell me what other strategy was being used.

_____________________________________________________________________________

21. I am going to read you a list of factors that may have contributed to your IIE. As I read each one, please tell me whether or not the factor contributed to your [IIE]. (Please select all that apply) (Read categories.)

	Yes	No	DON’T KNOW
a) Weather conditions
b) Road conditions
c) Lighting conditions
d) Mechanical problems with a vehicle
e) Another factor

*Programming note: If 21 = a, GOTO 22

*Programming note: If (21 NE a) and (21 = b), SKIP to 23

*Programming note: If (21 NE a) AND (21 NE b) AND (21 = c), SKIP to 24

*Programming note: If (21 NE a) AND (21 NE b) AND (21 NE c) AND (21 = d), SKIP to 25

*Programming note: If (21 NE a) AND (21 NE b) AND (21 NE c) AND (21 NE d) AND (21 = e), SKIP to 26

*Programming note: If (21 NE a) AND (21 NE b) AND (21 NE c) AND (21 NE d) AND (21 NE e), SKIP to 1 in Violence

22. [If 21 = a] Please describe the weather conditions.

_____________________________________________________________________________

*Programming note: If 21 = b, GOTO 23

*Programming note: If (21 NE b) AND (21 = c), SKIP to 24

*Programming note: If (21 NE b) AND (21 NE c) AND (21 = d), SKIP to 25

*Programming note: If (21 NE b) AND (21 NE c) AND (21 NE d) AND (21 = e), SKIP to 26

*Programming note If 21 NE b, c, d, or e, SKIP to 1 in Violence

23. [If 21 = b] Please describe the road conditions.

_____________________________________________________________________________

*Programming note: If 21 = c, GOTO 24

*Programming note: If (21 NE c) AND (21 = d), SKIP to 25

*Programming note: If (21 NE c) AND (21 NE d) AND (21 = e), SKIP to 26

*Programming note: If 21 NE c, d, or e, SKIP to 1 in Violence

24. [If 21 = c] Please describe the lighting conditions.

_____________________________________________________________________________

*Programming note: If 21 = d, GOTO 25

*Programming note: If (21 NE d) and (21 = e), SKIP to 26

*Programming note: If 21 NE d or e, SKIP to 1 in Violence

25. [If 21 = d] Please describe the problems with the vehicle.

_____________________________________________________________________________

*Programming note: if 21 NE e, SKIP to 1 in Violence

26. [If 21 = e] Please describe the factors that contributed to the incident when your [IIE] occurred.

_____________________________________________________________________________

Violence

1. Assault or violent incidents may include hitting, verbal assaults, and threats, even if harm was not intended. Did your [IIE] involve an assault or violent incident by a person?

1. Yes (GOTO Instruct_11)

2. No (SKIP to 1 in Struck by Object)

3. DON’T KNOW (SKIP to 1 in Struck by Object)

Instruct_11. I’m now going to ask you some additional questions about the incident you were involved in when your [IIE] occurred.

2. [If 1 = a] Harm can be intended or unintended. Do you think the person intended to harm you?

1. Yes

2. No

3. DON’T KNOW

3. Verbal assault includes abusive language, threats of violence or injury, and gestures. Did you experience a verbal assault?

4. Yes

5. No

6. DON’T KNOW

4. Physical assault includes unwanted physical contact including slapping, hitting, pushing, or kicking. Did you experience physical assault?

1. Yes

2. No

3. DON’T KNOW

*Programming note: If 3 = b AND 4 = b, GOTO to 5

*Programming note: If 3 NE b OR 4 NE b, SKIP to 6

5. [If 3 = b AND 4 = b] Please describe the assault or violence you experienced.

_____________________________________________________________________________

6. Were police present at the time of the incident?

1. Yes

2. No (GOTO 7)

3. DON’T KNOW

*Programming note: If 6 = a or c, SKIP to 8

7. Were police called when the incident occurred?

1. Yes

2. No

3. DON’T KNOW

8. Was a police report made because of the incident?

1. Yes

2. No

3. DON’T KNOW

9. Was a weapon used by the person who assaulted you?

1. Yes (GOTO 9)

2. No

3. DON’T KNOW

*Programming note: If 9 = b or c, SKIP to 11

10. [If 9 = a] Please describe the weapon or weapons used.

_____________________________________________________________________________

11. Do you suspect the person who assaulted you was under the influence of alcohol?

1. Yes

2. No

3. DON’T KNOW

12. Was there more than one person who assaulted you?

1. Yes (GOTO 13)

2. No

3. DON’T KNOW

*Programming note: If 12 = b or c, SKIP to 14

13. [If 12 = a] How many?

_____________________________________________________________________________

14. The person who assaulted you may have been a patient, a family member of a patient or just a bystander. Please tell me who the person or persons were.

_____________________________________________________________________________

15. Were you wearing a bullet proof vest when your [IIE] occurred?

1. Yes

2. No (GOTO 16)

3. DON’T KNOW

*Programming note: If 15 = a or c, SKIP to 1 in Struck by object

16. Was a bullet proof vest available to you?

1. Yes

2. No

3. DON’T KNOW

Struck by object

1. Injuries may be caused by getting struck or hit by an object, such as a tool, a piece of equipment, falling glass, debris, or other material. This does not include physical assaults by another person or incidents involving motor vehicles. Were you struck or hit by an object when your [IIE] occurred?

1. Yes (GOTO 2)

2. No (SKIP to 1 in Contact w/objects)

3. DON’T KNOW (SKIP to 1 in Contact w/objects)

2. [If 1 = a] Please describe the object that you were struck or hit by.

_____________________________________________________________________________

3. Please describe the factors that contributed to your [IIE].

_____________________________________________________________________________

Contact w/objects

1. Injuries may also occur when you come into contact with an object. This includes stepping on a nail, running into a piece of furniture, or grabbing a hot or electrically charged object. Did your [IIE] involve contact with an object?

1. Yes (GOTO 2)

2. No

3. DON’T KNOW

*Programming note: If (1 = b or c) AND ((1 in Overexertion = a) OR (1 in Exposure to heat = a) OR (1 in Exposure to potentially harmful substance = a) OR (1 in Falls/Slips/Trips = a) OR (1 in Transportation = a) OR (1 in Struck by Object = a)), SKIP to Instruct_12

*Programming note: If (1 = b or c) AND ((1 in Violence = a, b, or c) AND (none of the other events were chosen), SKIP to Instruct_13

*Programming note: If (1 = b or c) AND (none of the other events were chosen), SKIP to Instruct_13

2. [If 1 = a] Please describe the object that you contacted when your [IIE] occurred.

_____________________________________________________________________________

3. Please describe the factors that contributed to your [IIE].

_____________________________________________________________________________

*Programming note: If 2h (Overexertion and strains) = 1 OR 3e (Falls/Slips/Trips) = 1, SKIP to Instruct_12

4. When your [IIE] occurred, were you rushing to complete a task?

1. Yes

2. No

3. DON’T KNOW

Personal Protective Equipment

Instruct_12. Now I have some questions about any personal protective equipment or PPE you may have been using or wearing when your [IIE] occurred. Even though you have already described the incident, I do not want to overlook any important details.

1. I am going to read you a list of PPE that you may have been using. As I read each item, please tell me whether or not you were wearing that specific PPE.

	Yes	No
a) Protective gown
b) Goggles or safety glasses for medical care
c) Surgical mask not for fires
d) Latex or other type of disposable medical gloves
e) Bunker coat
f) Bunker pants
g) Helmet
h) Fire fighting gloves
i) Extrication gloves
j) Self-contained breathing apparatus or SCBA
k) SCBA mask
l) Protective hood
m) Goggles or face shield for fire fighting or extrication purposes
n) High-visibility vest
o) Boots
p) Brush suit or nomex
q) DON’T KNOW

*Programming note: If 1o = 1, GOTO 2

*Programming note: If 1o NE 1 AND (Exposure to heat AND fire type = wildland), SKIP to 4

*Programming note: If 1o NE 1 AND (fire type NE wildland) AND 1j = 1, SKIP to 5

*Programming note: If 1o NE 1 AND (fire type NE wildland) AND 1j NE 1, SKIP to 9

*Programming note: If 1q = 1, SKIP to Instruct_13

2. [If 1o = 1] You told me that you were wearing boots. Did the boots fit?

1. Yes

2. No (GOTO 3)

*Programming note: If 1 = a AND (Exposure to heat AND fire type = wildland), SKIP to 4

*Programming note: If 1 = a AND (fire type NE wildland) AND 1j = 1, SKIP to 5

*Programming note: If (fire type NE wildland) AND 1j NE 1, SKIP to 9

3. Were the boots too large?

1. Yes

2. No

*Programming note: If (Exposure to heat AND fire type = wildland), GOTO to 4

*Programming note: If (fire type NE wildland) AND 1j = 1, SKIP to 5

*Programming note: If (fire type NE wildland) AND 1j NE 1, SKIP to 8

4. I understand that you were exposed to heat, flames, or smoke during a wildland fire. At the time of your [IIE], were you using a fire shelter?

1. Yes

2. No

*Programming note: If 1j = 1, GOTO 5

*Programming note: If 1j NE 1, SKIP to 9

5. [If 1j = 1] You told me that you were wearing an SCBA. Were you using the SCBA at the time your [IIE] occurred?

1. Yes

2. No

3. DON’T KNOW

6. Was the SCBA inspected on a regular basis?

1. Yes

2. No

3. DON’T KNOW

7. Was the SCBA equipped with an integrated personal alert safety system or PASS?

1. Yes

2. No

3. DON’T KNOW

*Programming note: If 5 = a, GOTO 8

*Programming note: if 5 = b or c, SKIP to 9

8. [If 5 = a] Who was the manufacturer of the SCBA?

_____________________________________________________________________________

*Programming note: If 8c (Incident characteristics) = 1, SKIP to Instruct_13

9. Did you need any PPE that was NOT available?

1. Yes (GOTO 10)

2. No

3. DON’T KNOW

*Programming note: If 9 = b or c, SKIP to 11

10. Please describe the PPE that you needed.

_____________________________________________________________________________

11. Was the PPE that you were wearing appropriately donned?

1. Yes (GOTO 12)

2. No

3. DON’T KNOW

*Programming note: If 11 = b or c, SKIP to 13

12. Please explain what PPE was not appropriately donned.

_____________________________________________________________________________

13. Were there any problems with any of the PPE that you were wearing or using that may have contributed to your [IIE]?

1. Yes (GOTO 14)

2. No

3. DON’T KNOW

*Programming note: If 13 = b or c, SKIP to Instruct_13

14. Please describe the problems.

_____________________________________________________________________________

Injury/exposure outcome

Instruct_13. I’m now going to ask some questions about follow-up care and problems related to your [IIE] that you may have experienced after your visit to the ED.

1. After your ED visit, did you have any follow up care from a healthcare provider for your [IIE]?

1. Yes (GOTO 2)

2. No

3. DON’T KNOW

*Programming note: If 1 = b or c, SKIP to 3

2. [If 1 = a] Please describe your additional care after your ED visit, including the type of professional who performed the treatment and what type of treatment you received.

_____________________________________________________________________________

3. Have you returned to your fire fighting duties?

1. Yes

2. No (GOTO 4)

3. DON’T KNOW

*Programming note: If 3 = a, SKIP to 6

*Programming note: If 3 = c, SKIP to 9

4. [If 3 = b] Why have you not returned? Is it because you….? (Read categories.)

1. Are still recovering

2. Were fired or let go

3. Quit

4. Haven’t returned for another reason (GOTO 5)

5. DON’T KNOW

*Programming note: If 4 = a, b, c, or e, SKIP to 9

5. [If 4 = d] Please describe the reason you have not returned to your fire fighting duties.

_____________________________________________________________________________

*Programming note: If 4 = d, SKIP to 9

6. [If 3 = a] After your [IIE], when did you feel well enough to return to your fire fighter duties? (Read categories.)

1. The same day your [IIE] occurred

2. The day following your [IIE] or your next scheduled workday

3. Within 2 days to one week

4. Within 2 to 4 weeks

5. More than 4 weeks

6. DON’T KNOW

*Programming note: If (3 = a) AND (6 = c, d, or e), GOTO 7

*Programming note: If 6 = a, b, or e, SKIP to 9

7. [If (3 = a) AND (6 = c, d, or e)] In the 7 days after your [IIE], how much did your [IIE] limit your ability to do normal fire fighting duties? (Read categories.)

1. Not at all

2. Very little

3. Somewhat

4. Quite a lot

*Programming note: If 1 (Exposure to a potentially harmful substance) = a, SKIP to 10

8. Normal activities that you may do at home include cooking, inside or outside chores, or child care. In the 7 days after your [IIE], how much did your [IIE] limit your ability to do normal activities at home? (Read categories.)

1. Not at all

2. Very little

3. Somewhat

4. Quite a lot

*Programming note: If 7 = a AND 8 = a, SKIP to 11

9. Some people will experience permanent disability, long-term pain, limited movement, or difficulties in participating in daily activities due to their [IIE]. As of today, do you continue to have any of these effects from your [IIE]?

1. Yes (GOTO 10)

2. No

3. DON’T KNOW

*Programming note: If 10 = b or c, SKIP to 11

10. [If 9 = b] Please describe the affects you are experiencing as a result of your [IIE].

_____________________________________________________________________________

11. In your opinion, could your department have taken steps to prevent your [IIE]?

1. Yes (GOTO 12)

2. No

3. DON’T KNOW

*Programming note: If 11 = b or c, SKIP to Instruct_14

12. What recommendation would you make to your fire department to prevent other fire fighters from experiencing an [IIE] like yours?

_____________________________________________________________________________

Employment questions

Instruct_14. Now, I would like to ask you some specific questions about your job and your department.

1. What was your job title when your [IIE] occurred? Were you….? (Read categories.)

1. A fire fighter recruit or a probationary member

2. A fire fighter

3. An officer (GOTO 4)

4. Some other title

5. DON’T KNOW

*Programming note: If 1 = a, b, or e, SKIP to 4

*Programming note: If 1 = d, SKIP to 3

2. [If 1 = c] Please specify the rank that you held.

_____________________________________________________________________________

*Programming note: If 1 = c, SKIP to 4

3. [If 1 = d] Please describe your job title.

_____________________________________________________________________________

4. I am now going to read you a list of possible certifications that you may have. Please tell me whether or not you have any of the following.

	Yes	No
a) Fire fighter I
b) Fire fighter II
c) Apparatus driver or operator
d) Fire officer, any level
e) Hazmat, any level
f) Wildland fire fighter, any level
g) Technical rescue, any type
h) Paramedic
i) EMT, any level
j) Emergency medical responder
k) DON’T KNOW

*Programming note: If 2 (Screen) = a or b, GOTO to 5

*Programming note: If 2 (Screen) NE a or b, SKIP to 6

5. [If 2 (Screen) = a or b] In the past 12 months, about how many total hours of fire fighting training have you participated in? (Unknown = 999)

NumTrainHours _____________

6. In the past 12 months, have you participated in live fire training?

1. Yes

2. No

3. DON’T KNOW

7. On average, how many working fire calls of any type do you run in a MONTH? (Unknown = 999)

NumFireCalls _____________

8. On average, how many calls, other than working fire calls, do you run in a WEEK? (Unknown = 999)

NumNFireCalls _____________

9. At the time of your [IIE], about how many years total had you worked, either as a volunteer or career fire fighter? (Unknown = 99)

Years _____________

Months _____________

10. When your [IIE] occurred, about how many years had you worked with the department you were with either as a volunteer or career fire fighter? (Unknown = 99)

Years _____________

Months _____________

11. When your [IIE] occurred, did the department have a procedure for reporting occupational injuries, illnesses, or exposures?

1. Yes

2. No

3. DON’T KNOW

12. Did your department have a respirator fit-test program?

1. Yes

2. No

3. DON’T KNOW

Instruct_15. For the next series of statements, please think about when your [IIE] occurred and the department that you were with. For each statement, do you strongly agree, slightly agree, neither agree nor disagree, slightly disagree, or strongly disagree.

13. Fire fighter personnel input was well received by your department.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

14. Your department did a good job of training new personnel.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

15. Your department did a good job of providing periodic training to all personnel.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

16. The officers at your department supported your daily efforts.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

17. You received appropriate feedback about your performance.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

18. In your department, it was difficult to discuss errors.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

19. Your department was a good place to work.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

20. The culture at your department made it easy to learn from the errors of others.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

21. At your department, it was difficult to speak up if you perceived a problem with safety.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

22. Morale at your department was high.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

23. You had the training to do your job safely.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

24. At your department, personnel were hesitant to report errors due to fear of punishment.

Interviewer: If the respondent hesitates, please re-read the categories below.

1. Strongly agree

2. Slightly agree

3. Neither agree nor disagree

4. Slightly disagree

5. Strongly disagree

Current health status and demographics

Instruct_16. Finally, I’m going to ask a few questions about yourself.

1. In what month and year were you born?

Month (MM) _____________

Year (YYYY) _____________

2. In the past 12 months, have you had any other injuries or exposures related to your duties as a fire fighter that required more than first aid treatment?

1. Yes

2. No

3. DON’T KNOW

3. In the past 12 months, have you had a medical examination?

Interviewer: If the respondent asks, please let the respondent know that any physical counts.

1. Yes

2. No

3. DON’T KNOW

4. REFUSED

4. About how much do you weigh without shoes? (Unknown = 999)

Weight _____________

5. About how tall are you without shoes? (Unknown = 999)

Feet _____________

Inches _____________

6. Please tell me which of the following best describes the highest level of education you completed. (Read categories.)

1. Did not complete high school

2. High school or GED

3. Some college, including current college student

4. College degree

5. Graduate degree

6. Other (GOTO 7)

7. DON’T KNOW

*Programming note: If 6 = a, b, c, d, e, or g, SKIP to 8

7. [If 6 = f] Please describe the highest level of education you completed.

_____________________________________________________________________________

8. Are you of Hispanic, Latino, or Spanish origin?

Interviewer: If the respondent hesitates or says don’t know, say the following: This includes people from, or descended from, Spain, Mexico, Puerto Rico, Cuba, The Dominican Republic, or from Central or South America. Hispanics or Latinos may be of any race.

1. Yes

2. No

3. DON’T KNOW

4. REFUSED

9. Which of the following race or races describe you. (Please select all that apply) (Read categories.)

1. White

2. Black or African-American

3. Asian

4. Native American or Alaska Native

5. Native Hawaiian or Pacific Islander

6. Other

7. DON’T KNOW

8. REFUSED

Thank you for your participation. We greatly appreciate your cooperation.

End interview