Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Public reporting burden of this collection of information is estimated to average 15 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).
Attachment E-5. Adolescent Survey - English
Table of Contents
Variables used in Programming:
CALLTYPE denotes if the sample is for a landline or cell phone number
1 = LANDLINE
INTTYPE denotes who the interview is being conduct with
A = Adult, non-parent interview
P = Proxy interview with adult
D = Direct adolescent interview
NOTE: All responses in caps will not be read to the respondent. They are for interviewer coding only.
ask if SPST2=1
ADOL1. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries in children and adults.
You may have heard about head injuries, especially those experienced by children who play sports.
Even if you haven’t had an injury in the past 12 months, you can still participate in this important study. We have asked your parents to give their permission for you to participate; they have said “yes.” However, even though your parents said “yes,” you can still say “no” and not participate. And you can skip any question or stop the survey at any time. The majority of respondents will complete the survey in less than 8 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. CDC will keep the information that you provide private and secure to the extent permitted by the law. Your name will never be connected to your answers. We will not share your answers with your parents.
If you have questions or concerns about participating in the study, you may contact ICF International, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.
May we begin?
01. YES [SKIP TO TRANS1]
02. NO
ASK IF CALLTYPE =2
SAFE. Your safety is important. Are you driving in a car, or in a place where talking on the phone might distract you or jeopardize your safety or confidentiality?
01 YES
02 NO
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=2 AND SAFE=01
UNSAFE. I would like to call you at a more convenient time. What day and time would be best?
01 SCHEDULE CALLBACK
99 REFUSED [TERMINATE, ASSIGN DISP]
ask if inttype = a, p, or d
When adult or proxy reports for child display: “Now I'd like to ask some questions about your [insert age/sex of child] child.”
RECALL. We are interested in learning about times, in the last year, when [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experienced a head injury. This might have been from a bump, blow or jolt to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head.
CONTINUE
ASK if inttype=a, p or d
INJ. In the last year, that is since [insert date 1 year ago from today], [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] examined in a doctor’s office, clinic, hospital or elsewhere because of a head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJ =1
INJN. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] have that caused [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] to go to a doctor’s office, clinic, or hospital or to be examined elsewhere?
ENTER COUNT: ______[0-96]
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d
PREJOG. Now I’d like for you to think about (IF YES TO TREATED TBI “other”) times in the last year when [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] may have experienced an injury to the head. I would like you to tell me about a head injury even if [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] did not go to see a doctor for care. This might have happened while playing a sport for fun or competition, or while [IF INTTYPE=A READ “you were”/ IF INTTYPE=P READ “your child was”] doing something physically active like bicycling. It might have happened as a result of a car accident or because someone hurt [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”]. Or, it could have happened because [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] tripped, slipped, or fell down.
CONTINUE
ASK if inttype=a, p or d
INJ2. In the last year, that is since [insert date 1 year ago from today], did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience any other injuries to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head that you did not see a doctor about?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJ2 =1
INJN2. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience that you did not see a doctor about?
ENTER COUNT: ______[0-96]
97. DON’T KNOW
99. REFUSED
PROGRAMMER: CREATE INJNUM= INJN + INJN2 IF INJN < 97 AND INJN2 <97. if injn and injn2 are both dk/refused, create sysinjn=1. Set sysinjn=injnum so that respondents move thru the survey as if they have had one injury
if inj and inj2=2 (no injuries) skip to PNCLOSE
ASK if inttype=a, p or d and injn and injn2 =1-96. So we only confirm the number if we have a number.
/if INJNUM=1 then *textsub=injury/lesión; if injnum>1 then *textsub=injuries/lesiones /
INJNTOT. So to confirm, [IF INTTYPE=A OR D READ “you have”/ IF INTTYPE=P READ “your child has”] had [INSERT INJNUM] IF INJNUM>1 READ “separate”] head *textsub* in the past 12 months?
01. YES
02. NO (REASK AND CORRECT)
97. DON’T KNOW
99. REFUSED
programmer: first loop begins here from preintx to monthb for up to three injuries.
/if one injury do not display We will begin with your most recent head injury.
ASK if inttype=a, p or d and INJn >=1
PREINTX. Thank you. Now we have some more questions about [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “your child’s”] head [IF INJN + INJN2 =1 READ “injury”/ IF INJN + INJN2 >1 READ “injuries”]. We will begin with your most recent head injury.
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >1
Loop2 read: second most recent; loop 3 read: third most recent
INJOPNB. Can you provide a very brief two or three word description of your [IF INTTYPE=P READ “child’s”] most recent head injury? For example, “car accident” or “soccer injury”. We will talk about your other head injuries next.
INTERVIEWER: write brief DESCRIPTION
01. _______ [ENTER RESPONSE TEXT RANGE= XXXX]
97 DON’T KNOW
99 REFUSED
ASK if inttype=a, p or d and INJN + INJN2 =>1 (need year even if it is only one injury)
QYEAR. In what year did the head injury occur?
XXXX [ENTER FOUR DIGIT YEAR]
9997 DON’T KNOW
99999 REFUSED
ask if year not in 2016, 2017
YEARVAL [insert response to year] is outside the range of years we are asking about. We are interested in head injuries that occurred since [insert date 1 year ago].
[IF ONLY ONE INJURY GO TO PNCLOSE]
[IF MORE THAN ONE INJURY GO TO NEXT LOOP]
ASK if inttype=a, p or d and INJN + INJN2 =>1 (need month even if it is only one injury)
QMONTH. In what month did the head injury occur?
01. JANUARY
02. FEBRUARY
03. MARCH
04. APRIL
05. MAY
06. JUNE
07. JULY
08. AUGUST
09. SEPTEMBER
10. OCTOBER
11. NOVEMBER
12. DECEMBER
97. DON’T KNOW
99. REFUSED
ask if year + month does not determine if injury occurred within past 6 months.
MONTHA. Did the head injury occur before or after [interview date – 180 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year +month does not determine if injury occurred within past year
MONTHB. Did the head injury occur before or after [interview date – 365 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year or month is 97, 99
ONEYR. Did the head injury occur before or after [interview date –365 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year or month is 97,99
SIXMO. Did the head injury occur before or after [interview date – 180 Days]?
BEFORE
AFTER
if injury happened more than one year ago (If monthb = 1 OR ONEYR=1) and there are no more injuries, respondent goes to lifetime TBI section.
programmer: second loop starts here from presymmu to actselx if INJN + INJN2 >= 1
refer to each injury using INJOPNb to remind the respondent which injury you are asking about
IF INJNUM>1 AND YEAR OR MONTH IS DK/REF FOR ANY INJURY IN THE LOOP THEN LOOP1 REPRESENTS THE MOST RECENT INJURY, LOOP2 REPRESENTS THE SECOND MOST RECENT INJURY, AND LOOP3 REPRESENTS THE THIRD MOST RECENT INJURY.
IN THESE CASES OF MISSING YEAR OR MONTH BECAUSE RESPONDENT ANSWERED DK/REF PRESYMMU SHOULD REFERENCE INJOPNB IF POPULATED AND MONTH IF POPULATED AS FOLLOWS
IF INJOPNB IS MISSING -
PRESYMMU. Now I’d like to discuss the injuries you told me about. [IF INJOPNB IS MISSING REFER TO LOOP NUMBER FOR TEXT INSERT.] LOOP1 READ: Please tell me about the injury you reported as the most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY ] that occurred in [MONTH]. LOOP2 READ: Please tell me about the injury you reported as your second most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY TEXT] that occurred in [MONTH]. LOOP3 READ: Please tell me about your injury you reported as your third most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY TEXT] that occurred in [MONTH].
IF MONTH IS MISSING AND INJOPNB POPULATED
PRESYMMU. Now I’d like to discuss the injuries you told me about. Please tell me about the injury you described as the [INJOPNB].
ASK if inttype=a, p or d and INJN + INJN2 >1
PRESYMMU. Now I’d like to discuss [IF SECOND AND THIRD LOOP display the next injury. [IF FIRST LOOP DISPLAY: the injuries you told me about]. [IF INJOPNB IS POPULATED READ “Let’s discuss the one you described as [INJOPNB]// IF MONTHN IS POPULATED READ “that occurred in [MONTHN].
CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM. In the next set of questions, I will be asking what happened to [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] immediately or in the minutes after this head injury. For each one I read, please tell me if it happened to [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] or not. We only want to know about things caused by the head injury or made worse by the head injury. [IF INTTYPE =P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
CONTINUE
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM1. [IF INTTYPE=A READ “Were you dazed, confused or did you have trouble thinking straight?” / [IF INTTYPE= P READ “Did your child have trouble thinking straight or appear to be out of it?” / [IF INTTYPE= D READ “Did you have trouble thinking straight or feel out of it?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM2. [IF INTTYPE=A OR D READ “Did you have difficulty remembering what happened just before or after the head injury?” / [IF INTTYPE= P READ “Did your child have difficulty remembering what happened just before or after the head injury?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM3. [IF INTTYPE=A OR D READ “Were you knocked out or did you lose consciousness, even briefly?” / [IF INTTYPE= P READ “Was your child knocked out or did your child lose consciousness, even briefly?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and sym3=1
SYM3A. For how long? Was it…
INTERVIEWER: IF RESPONDENT IS UNSURE, SAY, “It is okay to give your best guess.”]
INTERVIEWER: Read [INJOPNB] if needed.
01. A few seconds
02. More than a few seconds, up to 5 minutes
03. 6 to 30 minutes
04. 31 minutes to 24 hours, or
05. More than 24 hours
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM4. Now we’d like to ask you about things that happen to some people after a head injury. Some of these develop immediately or minutes after a head injury and some do not happen until later. Again, we only want to know about things caused by the head injury or made worse by the head injury. [IF INTTYPE =P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM4. [IF INTTYPE=A OR D READ “Did you feel sick to your stomach or did you vomit?” / [IF INTTYPE= P READ “Did your child complain of feeling sick to his or her stomach or did he or she vomit?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and SYM4=1
SYM4A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM5. Did [IF INTTYPE=A OR D READ “you have a headache?” / [IF INTTYPE=P READ “your child complain of a headache?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and SYM5=1
SYM5A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM6. [IF INTTYPE=A OR D READ “Was there ever a time when you were dizzy, clumsy or had balance problems?” / IF INTTYPE=P READ, “Did your child appear dizzy or complain of dizziness, appear to move in a clumsy way, or have balance problems?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 AND SYM6=1
SYM6A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM7. [IF INTTYPE=A OR D READ “Did you have blurred or double vision, or other changes in your vision?” / IF INTTYPE=P READ “Did your child have or complain about blurred or double vision, or other changes in vision?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1AND SYM7=1
SYM7A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM8. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] have trouble concentrating?
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 and SYM8=1
SYM8A. Did this start..
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM9. Earlier we asked about things that might have started immediately or minutes after a head injury. The next questions are about things that might happen to people sometime after. Again, we are only interested in things caused by the head injury, or made worse by the head injury. [IF INTTYPE=P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM9. [IF INTTYPE=A READ “Did you have difficulty learning or remembering new things?” / IF INTTYPE=P READ “Did your child become confused with directions or tasks or answer questions more slowly than usual?” / IF INTTYPE=D READ “Did you become confused with directions or tasks, or answer questions more slowly than usual?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM10. [IF INTTYPE=A OR D READ “Were you” / IF INTTYPE=P READ “Was your child”] more sensitive than usual to either light or noise?
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM11. [IF INTTYPE=A OR D READ “Did you experience a change in mood or temperament such as irritability, or feel more emotional than usual?” / IF INTTYPE=P READ “Was there a change in your child’s mood or temperament, were they more irritable, or otherwise more emotional than usual?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM12. [IF INTTYPE=A OR D READ “Did you have trouble sleeping or were you more tired than usual?” / IF INTTYPE = P READ “Did your child have trouble sleeping or appear more tired than usual?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and INJN + INJN2 >= 1
SRRX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while playing a sport, or while engaged in physical fitness or a recreational activity for fun or competition?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a, p or d and srrX=1
ACTSELX. Which activity [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] doing at the time of the head injury?
Aerobics, cardio
Balance beam
Balance rope
Ballet
Barrel racing
Base jumping
Baseball
Basketball, shooting hoops
Bicycling Biking or Cycling
Boxing, Sparring
Bungee jumping
Burpees
Calisthenics
Canoeing
Cheerleading
Circuit training
Climbing (ice, rock)
Climbing wall, net, bars
Conditioning, warm-up (gymnastics)
Crew
Cross fit
Dancing (any kind)
Diving, jumping into water
Dodgeball
Elliptical
Equestrian
Floor exercises
Football
Foursquare
Guns, firearms
Gym equipment
Gymnastics
Hang gliding
Heptathlon
High bar
Hiking
Hockey (field, ice)
Hopscotch
Horse (riding, racing)
Hover boarding
Hunting
Inner-tubing (water)
Javelin
Jiu-jitsu
Judo
Jumping jacks
Jungle gym
Karate
Kayaking
Lacrosse
Lifting weights, free weights
Long jump, high jump, triple jump
Martial arts (Mixed, MMA)
Monkey bars
Motor vehicle (car, truck, offroad, dirt bike, motorcycle)
Muay thai
Parachuting, paragliding, parasailing
Parallel bar or uneven bars
Parkour
Pilates
Ping pong/ table tennis
Playground activity
Pole bending (rodeo)
Pole vaulting
Polo
Pommel horse
Racquetball
Rafting (water)
Red rover
Riding stock
Rings (still)
Rodeo
Roping
Rowing machine
Rugby
Running, jogging
Sailing
Scuba diving
Shooting skeet, targets or for competition
Shot put
Skateboarding/long boarding
Skating, ice or figure
Skating, inline
Skating, roller
Ski jumping
Skiing
Sledding (snow)
Slide, slide pole, sliding
Snorkeling
Snowboarding
Snow tubing
Soccer
Softball
Squash
Stair climber
Stationary bike
Steer wrestling
Stretching, flexibility
Surfing
Swimming
Swings, swinging
Tae Kwon Do
Tag
Teeter totter, see-saw
Tennis
Tetherball
Track and field
Treadmill
Triathlon
Ultimate frisbee
Vault
Volleyball, indoor
Volleyball, outdoor
Walking
Water Polo
Water Tubing
Wrestling
Yoga
Zip lining
Zumba
None of these/other: ENTER: XXXXXXX
programmer: if there is more than one injury, go back through signs/symptoms to actselx for the next injury for up to three injuries per A, P or D.
CASE DEFINITION: if there is one injury with symptoms, goto intentx. if there is one injury without symptoms, goto txmostns. IF > 1 For either, refer to the MOST RECENT injury.
MOST RECENT INJURY NO SYMPTOMS
TXMOSTNS.
This part of the survey is about [IF INTTYPE=A or D READ “your”; IF INTTYPE=P READ “your [AGE] year old” IF MALE “son” IF FEMALE “daughter]’s injury [IF INJOPNB IS POPULATED READ “, which you described as the [INSERT INJOPNB]”] {IF MONTH POPULATED DISPLAY: “that occurred in [MONTH]”} [IF MONTH and INJOPNB missing (DK OR REF) “{IF INJURY IN LOOP1: “most recent injury you reported”; IF INJURY IN LOOP2 “second most recent injury you reported”; IF INJURY IN LOOP3 “third most recent injury you reported”].
ask if inttype = D (This question ONLY includes MOST RECENT INJURY with no symptoms)
DASSESSEDN. Did anyone check you out to see if you were injured?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and if DASSESSED =2 (This question ONLY includes MOST RECENT INJURY with no symptoms)
PRETELLN. Although you were not checked out for your head injury, did you tell anyone?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and PRETELL = 2 (This question ONLY includes MOST RECENT INJURY with no symptoms)
mult=4 [Note select all that apply instructions below]
NOTELLWHYN. Why did you choose not to tell anyone? Was it because you…
interviewer: select all that apply.
Did not realize you were injured
Did not think the head injury was serious
Did not want to be removed from your sport
95. Some other reason [ENTER RESPONSE [TEXT RANGE = XXX]
97. DK/NR
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >=1(This question ONLY includes MOST RECENT INJURY with no symptoms)
FUNCSN. To what extent did the head injury interfere with [IF INTTYPE=A or D READ “your”; IF INTTYPE=P READ “your child’s”] normal social activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
97. DON’T KNOW
99. REFUSED
ASK if inttype= p or d and INJN + INJN2 >=1 (This question ONLY includes MOST RECENT INJURY with no symptoms)
FUNCSAN. To what extent did the head injury interfere with [IF INTTYPE=D READ “your”; IF INTTYPE=P READ “your child’s”] normal school activities (including extracurricular activities such as sports, band or clubs)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
DON’T KNOW
REFUSED
MOST RECENT INJURY SYMPTOMS
ask if inttype=a, p, or D and INJN + INJN2 >= 1 AND SRRX=2,97
INTENTX. We have additional questions about your [IF INJN+INJN2 = 1, READ injury//IF INJN+INJN2>1, READ “most recent injury, IF INJOPNB_1 IS POPULATED READ “which you described as the [INSERT INJOPNB_1]. Which of the following best describes how the head injury happened? Would you say that…
01. Someone else was trying to injure [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] on purpose
02. [IF INTTYPE=A OR D READ “You”/ IF INTTYPE=P READ “Your child”] tried to injure [IF INTTYPE=A OR D READ “yourself”/ IF INTTYPE=P READ “him or herself”] on purpose
03. It was an accident—no one intended to injure [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”], or
95. Something else happened? [ENTER RESPONSE TEXT RANGE=XXXX]
97. DON’T KNOW
99. REFUSED
ASK IF inttype = a, p, or d and INJN + INJN2 >1 AND SRRX<>2
TXMOST. This part of the survey is about [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “your AGE year old GENDER child’s”] most recent injury [IF INJOPNB IS POPULATED READ “, which you described as the [INSERT INJOPNB]”].
ask if inttype=a, p, or d and INJN + INJN2 >= 1 and srrX = 2,97 and intentx=3,95,97
BIKEX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while on a bicycle?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and BIKEX=1 or (srrx=1 and actselX=9)
BIKE1X. How did the head injury happen? Was it initially due to a…
01. Collision with a moving motor vehicle
02. Collision with another bicycle
03. Collision with a person
04. Collision with a stationary object
05. Fall from a bicycle to a surface like the road, or
95. Something else?
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and BIKEX=1 and srrx <>1
BIKE4X. What was the PRIMARY reason [IF INTTYPE=A OR D READ “you were”/ IF INTTYPE=P READ “your child was”] bicycling at the time of the head injury? [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”]…
01. Riding primarily as a means of transportation--for example to get to work or school
02. Riding primarily for recreation, physical fitness, or competition
03. BOTH
97. DON’T KNOW
99. REFUSED
programmer: if bike4x =2, create variable “BIKESRRact”=1
ask if inttype=a, p, or d and INJN + INJN2 >= 1 and milblastx<>1 and srrX = 2,97 and bikex=2,97
MVX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while on or in a motorized vehicle, such as a car, bus, truck, motorcycle, dune buggy, or all-terrain vehicle (ATV)?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, P, or d and mvX=1 and srrx<>1 and MV3X = 3, 4, or 5
MV7X. Why [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] riding or driving at the time of the head injury? [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”]
01. Riding or driving as a means of transportation-- for example to get to work or school
02. Riding or driving for fun, for pleasure, or for competition
97. DON’T KNOW
99. REFUSED
programmer: if MV7X =2, create variable “MVSRRact”=1
ask if inttype=a, p, or D and INJN + INJN2 >= 1 and srrx=2,97 and milblastx<>1 and bike = 2,97 and mvx = 2,97 and INTENTX <>2
CAUSEX. Would you say that the head injury occurred because …
[IF INTTYPE=A OR D READ “You were”/ IF INTTYPE=P READ “Your child was”] hit by an object or person, or were pushed against something
IF INTTYPE=A OR D READ “You”/ IF INTTYPE=P READ “Your child”] fell without being struck or pushed, or
95. Something else happened [ENTER RESPONSE TEXT RANGE=XXXX]
97. DON’T KNOW
99. REFUSED
ask if MV3X=3,4 or bikex=1, or ACTSELX =6, 7, 9, 93, 28, 37, 5, 26, 39, 63, 65, 70, 72, 73, 97, 33, 57, 81, OR 119
HELMETX. [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”] wearing a helmet at the time of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if ACTSELX =85, 86, 87, 90, or 91
HELMET1X. [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”] wearing a helmet or headgear at the time of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYMSTILL. [IF INTTYPE=A OR D READ “Are you”/ IF INTTYPE=P READ “Is your child”] still experiencing any of the head injury-related symptoms that we’ve talked about?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 and SYMstill=2
/Validate against date of injury if provided and restrict number of days, weeks, months accordlingly/
/if month and YEAR missing display:
Earlier you reported your head injury occurred within the past 12 months. Please provide the number of months it took for your symptoms to go away; your answer should be 12 months or less.
/IF MONTH and YEAR POPULATED DISPLAY:
Earlier you reported your head injury occurred within the past 12 months. How many months since [MONTH] [YEAR] did it take for your head injury-related symptoms to go away? Your answer should be 12 months or less.
SYMRECA. How long did it take for all of [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head injury-related symptoms to go away? You can report either the number of days, weeks, or months.
01. NUMBER OF DAYS
02. NUMBER OF WEEKS
03. NUMBER OF MONTHS
97. DON’T KNOW
99. REFUSED
ask if inttype = D (This question now includes injuries with no symptoms)
DASSESSED. Did anyone check you out to see if you were injured?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and DASSESSED =1
DBYWHOA. Who were you first assessed by?
01. A school nurse
02. Your regular doctor or pediatrician
03. An EMT or paramedic
04. An athletic trainer
05. A coach
06. A parent
07. A specialist such as a sports medicine doctor or neurologist
08. Another medical professional, or
95. Someone else [ENTER RESPONSE [TEXT RANGE = XXX]
97. DK/NR
99. REFUSED
ask if inttype = D and dassessed = 1 and DBYWHOA = 4, 5, 6 or 95
DBYWHOB. After you were checked out by [INSERT TEXT ANSWER FROM DBYWHOA], were you checked out by any of the following people? Please say “yes” or “no” to each one.
01. Your regular doctor or pediatrician
02. A specialist such as a sports medicine doctor or neurologist
03. Another medical professional, or
95. Someone else [ENTER RESPONSE [TEXT RANGE = XXX]
97. DK/NR
99. REFUSED
ask if inttype = D and if DASSESSED =2 (This question now includes injuries with no symptoms)
PRETELL. Although you were not checked out for your head injury, did you tell anyone?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and PRETELL = 2 (This question now includes injuries with no symptoms)
mult=4 [Note select all that apply instructions below]
NOTELLWHY. Why did you choose not to tell anyone? Was it because you…
interviewer: select all that apply.
Did not realize you were injured
Did not think the head injury was serious
Did not want to be removed from your sport
95. Some other reason [ENTER RESPONSE [TEXT RANGE = XXX]
97. DK/NR
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >=1
FUNCS. To what extent did the head injury interfere with your normal social activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
ASK if inttype= p or d and INJN + INJN2 >=1
FUNCSA. To what extent did the head injury interfere with your normal school activities (including extracurricular activities such as sports, band or clubs)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
//Ask all//
PNCLOSE. That was my last question. Thank you very much for participating in this important research study.
01 CONTINUE
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |