Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Public reporting burden of this collection of information is estimated to average 14 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-2. Adult-Proxy Screener - English
Table of Contents
Variables used in Programming:
CALLTYPE denotes if the sample is for a landline or cell phone number
1 = LANDLINE
2 = CELL
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.
INTRO1. 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 in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call. Your phone number has been chosen at random to represent thousands of others in the country.
01 CONTINUE
CFM00026. if ***([CALLTYPE#2])*** goto cell
ASK if calltype = 1 and intro1=01
ISADLT. Are you at least 18 years old and a resident of the United States?
01 YES
02 NO
98 DON’T KNOW [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO ]
IF ISADLT=98, 99
TERM_ISADLT. We are only interviewing adults 18 years and older at this time.
ASK IF CALLTYPE=1 AND ISADLT=2
GETADLT. May we please speak with an adult, 18 years of age or older?
01 YES
02 NO [schedule call back]
99 REFUSED [TERMINATE, ASSIGN DISPO]
IF GETADLT=99
TERM_GETADLT. We are only interviewing adults 18 years and older at this time.
ASK IF CALLTYPE=1 and getadlt=1
INTRO1A. 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 in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call. Your phone number has been chosen at random to represent thousands of others in the country.
CONTINUE
ASK if calltype=1
PRIVRES. Is this a private residence?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=1 ISADLT=01 OR INTRO1A=01
ADLTS. We need to gather some information about each household member, 18 years or older, so the computer can pick someone at random for the interview. How many members of your household, including yourself, are 18 years of age or older?
__ Number of adults [RANGE=0-18]
[TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=1 AND ADLTS=1
ONEADLT. So you are the adult in this household?
01 YES, AND RESPONDENT IS MALE
02 YES, AND RESPONDENT IS FEMALE
03 NO [REASK SERIES AT ISADLT TO DETERMINE IF ADULT OR NOT ]
04 YES, UNABLE TO TELL IF MALE OR FEMALE
CFM00028. RESET TO REASK_ADULT IF: ***([CALLTYPE#1] AND ONEADLT is NO )***
ASK IF CALLTYPE=1 AND ONEADLT=4
GENDER. What is your sex? 01 MALE
02 FEMALE
99 REFUSED
ASK IF CALLTYPE=1 AND adlts=2-18
WOMEN. How many of those adults are women?
ENTER NUMBER /RANGE = 0-9/
cALCULATE MEN = ADLTS-WOMEN
ASK IF CALLTYPE=1 AND adlts=2-18
V_MEN. How many of those adults are men?
ENTER NUMBER /RANGE = 0-9/
CFM00029. RESET TO PREADLTS IF: ***(V_MEN is NO )***
ASK IF CALLTYPE=1
PRENUMC. To help us ensure that we are talking to a representative selection of households in the United States, we have just a few additional questions about your household.
01 CONTINUE
ASK IF CALLTYPE=1
NUMC. How many children 17 years of age or younger are in your household?
ENTER NUMBER:
99 REFUSED
ASK IF calltype=1 and NUMC> 0 and < 99
ISPARNT. Are you the parent or guardian of [IF NUMC = 1 READ “this child” //IF NUMC >1 READ “one or more of these children”]?
01 YES
02 NO
99 REFUSED
ASK IF NUMC=1
AGESC1X. I’d like to ask a few questions about this child. How old is this child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC=1 and AGESC1X=01
AGESC1. ENTER AGE: [Range 0-17]
ASK IF NUMC=1
GENDC1. Is this child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>1 AND <99
CFM00031. I’d like to ask a few questions about each child. How old is the oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>1 AND CFM00031=01
CFM00032. ENTER AGE: [0-17]
ASK IF NUMC>1 AND <99
CFM00033. Is the oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>1
AGESC2_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>1 AND AGESC2_x=01
AGESC2X. ENTER AGE: [Range 0-17]
ASK IF NUMC>1
GENDC_2. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>2
AGESC3_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>2 AND AGESC3_x=01
AGESC3X. ENTER AGE: [Range 0-17]
ASK IF NUMC>2
GENDC_3. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>3
AGESC4_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>3 AND AGESC4_x=01
AGESC4X. ENTER AGE: [Range 0-17]
ASK IF NUMC>3
GENDC_4. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>4
AGESC5_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>4 AND AGESC5_x=01
AGESC5X. ENTER AGE: [Range 0-17]
ASK IF NUMC>4
GENDC_5. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>5
AGESC6_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>5 AND AGESC6_x=01
AGESC6X. ENTER AGE: [Range 0-17]
ASK IF NUMC>5
GENDC_6. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>6
AGESC7_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>6 AND AGESC7_x=01
AGESC7X. ENTER AGE: [Range 0-17]
ASK IF NUMC>6
GENDC_7. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF calltype = 1 and isparnt = 01
INFOR. This survey asks about health information and activities that children participate in. I need to speak to someone living in your household who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES
02 NO
88 NO CHILDREN IN HH
ASK IF CALLTYPE = 1 AND ONEADLT=01 or oneadlt=02 AND NUMC=0,99
ONEADLT2. You are the person I need to speak with.
01. CONTINUE
ASK IF CALLTYPE = 1 and adlts=2
programmer: screener adult is selected 50% of the time.
if screener adult is selected and no children in hh or infor=2 then send to CONEADLT consent and complete adult interview
if screener adult is selected continue with adult portion of interview. if infor=1 continue with proxy interviews too. use proxy consent.
if selected adult is not screener adult ask to speak with 2nd adult. If 2nd adult available send to intro1B. if second adult is not available and infor=1 complete proxy interview with adult on phone (use proxy consent) and then schedule cb with selected adult. if selected adult not available and no knowledgeable adult available schedule cb to contact 2nd adult
SELADLT : [Select randomly]
Screener adult
Other adult [Adult with most recent birthday if ADLTS>2 ]
TWOADLT. The person in your household I need to speak with is [EITHER SCREENER RESPONDENT OR OTHER RESPONDENT]. [IF NON-SCREENER RESPONDENT, READ “May I speak with him or her?]
01. SCREENER IS SELECTED ADULT
02. ADULT COMING TO THE PHONE [SEND TO INTRO1B]
03. SELECTED ADULT NOT AVAILABLE [IF INFOR=2 OR ISPARNT=2 SEND TO SPEAKTO]
04. SELECTED ADULT IS NOT AVAILABLE [IF INFOR=1 THEN SEND TO PROXY CONSENT AND COMPLETE PROXY INTERVIEW; SCHEUDLE CB TO CONTACT SELECTED ADULT]
ASK IF CALLTYPE = 1 and adlts=3-18
programmer: screener adult is selected 1/aTH of the time, where A is the number of adults.
IF CALLTYPE = 01 AND TWOADLT=03
SPEAKTO. I also need to speak to a parent or guardian living in your household who knows health and activities information for each child. Because the selected adult is not available, may I speak to the person who knows this information?
KNOWLEDGEABLE ADULT COMING TO THE PHONE
02. KNOWLEDGEABLE ADULT NOT AVAILABLE [SKIPTO TSTAT160]
If calltype = 01 and speakto = 01
INTRO1B. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head or neck injuries in children and adults. You may have heard about head injuries in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call.]
INFOR2. This survey asks about health information and activities that children participate in. I need to speak to parent or guardian living in your household who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES [GO TO CPROXY]
02 NO [GO TO CONEADLT]
00 NO CHILDREN IN HH
CALC SELECTED = PERSON ON PHONE 1/Ath OF TIME, WHERE A IS THE NUMBER OF ADULTS
IF SELECTED IS PERSON ON PHONE, CONTINUE ADULT PORTION OF INTERVIEW. IF SELECTED CAN REPORT ON CHLDREN (INFOR=01), CONTINUE WITH PROXY INTERVIEWS, TOO.
IF SELECTED IS NOT PERSON ON PHONE, ASK FOR ADULT WITH MOST RECENT BIRTHDAY.
IF THAT ADULT AVAILABLE, ASK IF HE/SHE CAN REPORT ON CHILDREN. IF SO, DO ADULT AND PROXY WITH THE SELECTED ADULT.
IF THAT ADULT NOT AVAILABLE, AND PERSON ON PHONE CAN REPORT ON CHILDREN, GET SCREENER ADULT (ONE ON THE PHONE) TO PROVIDE PROXY INFORMATION FOR CHILDREN. THEN SCHEDULE CALLBACK FOR SELECTED ADULT.
THREEADLT. Our study requires that we randomly select one person who lives in your household to be interviewed. The person from your household who has been randomly selected is [IF SELECTED ADULT IS SCREENED ADULT READ: you.] [IF SELECTED ADULT IS NOT SCREENED ADULT READ: the adult, not including yourself, with the next birthday.
May I speak with him or her?
01. SCREENER IS SELECTED ADULT
02. ADULT COMING TO THE PHONE [SEND TO INTRO1B THEN INFOR2 IF CHILDREN IN HH] [IF NO CHILDREN SEND TO INTRO1 B THEN CONEADLT]
03. SELECTED ADULT NOT AVAILABLE [IF INFOR=2 OR ISPARNT=2 SEND TO SPEAKTO]
04. SELECTED ADULT IS NOT AVAILABLE [IF INFOR=1 THEN SEND TO CPROXY CONSENT AND COMPLETE PROXY INTERVIEW; SCHEUDLE CB TO CONTACT SELECTED ADULT]
05. SELECTED ADULT NOT AVAILABLE AND NO CHILDREN IN HH [schedule CB]
INTTYPE denotes who the interview is being conduct with
A = Adult, non-parent interview
P = Proxy interview with adult
D = Direct adolescent interview
ASK if calltype = 2 and intro1=01
CISADLT. Are you at least 18 years old and a resident of the United States?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
98 DON’T KNOW [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=2 and CISADLT=2,98,99
TERM. We are only interviewing adults 18 years and older at this time.
ASK if calltype=2 AND CISADLT=01
CPRIVRES. Do you live in a private residence?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ask if calltype=2 and cprivres=01
CADLTS. How many adults 18 years of age or older, including yourself, are in your household?
__ Number of adults [RANGE=0-18]
[TERMINATE, ASSIGN DISPO]
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 DISPO]
ASK IF CALLTYPE=2
CPRENUMC. To help us ensure that we are talking to a representative selection of households in the United States, we have just a few additional questions about the members of your household.
CONTINUE
ASK IF CALLTYPE=2
CNUMC. How many children 17 years of age or younger are in your household?
ENTER NUMBER:
99 REFUSED
ASK IF calltype=2 and CNUMC> 0 and < 99
CISPARNT. Are you the parent or guardian of [IF CNUMC = 1 READ “this child” //IF CNUMC >1 READ “one or more of these children”]?
01 YES
02 NO
99 REFUSED
ASK IF calltype=2 and CNUMC> 0 and < 99
ASK IF CNUMC=1
CAGESC1X. I’d like to ask a few questions about this child. How old is this child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC=1 and cagesc1x=01
CAGESC1. ENTER AGE:[ Range 0-17]
ASK IF CNUMC=1
CGENDC1. Is this child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>1 AND <99
CFM00044. I’d like to ask a few questions about each child. How old is the oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>1 AND <99 AND CFM00044=01
CFM00045. ENTER AGE:[Range 0-17]
ASK IF CNUMC>1 AND <99
CFM00046. Is the oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>1
CAGESC2_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IFC NUMC>1 AND CAGESC2_x=01
CAGESC2X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>1
CGENDC_2. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>2
CAGESC3_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>2 AND CAGESC3_x=01
CAGESC3X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>2
CGENDC_3. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>3
CAGESC4_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>3 AND CAGESC4_x=01
CAGESC4X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>3
CGENDC_4. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>4
CAGESC5_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>4 AND CAGESC5_x=01
CAGESC5X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>4
CGENDC_5. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>5
CAGESC6_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>5 AND CAGESC6_x=01
CAGESC6X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>5
CGENDC_6. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>6
CAGESC7_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>6 AND CAGESC7_x=01
CAGESC7X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>6
CGENDC_7. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF calltype = 2 and Cisparnt = 01
CINFOR. This survey asks about health information and activities that children participate in. I need to speak to someone who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES
02 NO
88 NO CHILDREN IN HOUSEHOLD
ASK IF noT A PARENT/GUARDIAN OF children in household
CONEADLT. You have been randomly chosen to participate in an important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of up to 10,000 people in the United States to find out about their experiences with head injuries in the past 12 months. Even if you haven’t had an injury in the past 12 months, you can still participate in this important study.
The data we are collecting are very important, and will be used to guide national policies. The majority of respondents will complete the survey in less than 14 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your information private, your name will never be connected to your answers. CDC will keep the information that you provide private and secure to the extent permitted by the law. You can skip any question or stop the survey at any time. If you have questions or concerns about participating in the study, you may contact ICF, 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?
1. YES [SKIP TO TRANS1]
2. NO [SCHEDULE CALLBACK]
ASK IF PARENT/GUARDIAN OF children in household
CPROXY. You have been randomly chosen to participate in this important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of up to 10,000 people in the United States to find out about their experiences with head injuries in the past 12 months.
We will also ask you about the [IF NUMC=1 READ “child’s” / IF NUMC >1 READ “children’s”] experiences with head injuries in the past 12 months. Even if you or the [IF NUMC=1 READ “child has” / IF NUMC>1 READ “children have”] not had an injury in the past 12 months, you can still participate in this important study.
The data we are collecting are very important, and will be used to guide national policies. The majority of respondents will complete the survey in less than 20 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your information private, your name will never be connected to your answers. CDC will keep the information that you provide about you and the children private and secure to the extent permitted by the law. You can skip any question or stop the survey at any time. If you have questions or concerns about participating in the study, you may contact ICF, 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?
1. YES [SKIP TO TRANS1]
2. NO [SCHEDULE CALLBACK]
ASK if INTTYPE=a or P
TRANS1. Thank you. Before we continue with the rest of the survey, we have just a few questions for background purposes only.
ASK if INTTYPE=a
AGE. What is your age?
01. GIVES AGE
99. REFUSED
ASK IF age=01
AGE1. ENTER AGE:
ASK IF CALLTYPE=1 or 2 AND (ADLTS or CADLTS>1)
GENDER2. INTERVIEWER CODE RESPONDENT SEX
21 MALE
22 FEMALE
04 UNABLE TO TELL IF MALE OR FEMALE
aSK IF GENDER2=04
GENDER2A. What is your sex?
01 MALE
02 FEMALE
99 REFUSED
ASK if INTTYPE=a or p
HISPA. Are you Hispanic, Latino/a, or of Spanish origin?
01. No, not Hispanic, Latino or of Spanish origin
02. Yes, Hispanic, Latino, or of Spanish origin
97. DON’T KNOW
99. REFUSED
ASK if INTTYPE=a or p
/programmer: mul=5/
RACEA. Which one or more of the following would you say is your race?
INTERVIEWER: IF RESPONDENT SAYS “HISPANIC OR LATINO” SAY, “THANK YOU – I HAVE RECORDED THAT YOU ARE HISPANIC/LATINO. WOULD YOU SAY THAT YOU ARE WHITE, BLACK OR AFRICAN AMERICAN, AMERICAN INDIAN OR ALASKA NATIVE, ASIAN, NATIVE HAWAIIAN OR PACIFIC ISLANDER, OR MORE THAN ONE OF THESE?”
01 White
02 Black or African American
03 American Indian or Alaska Native
04 Asian, or
05 Native Hawaiian or other Pacific Islander
INTERVIEWER: DO NOT READ THE FOLLOWING OPTIONS
95 OTHER
97 DON’T KNOW
99 REFUSED
ASK if inttype=A or P
EDUC. What was the highest grade or year in school that you completed?
[DO NOT READ]
01. Didn’t graduate from high school
02. Received GED (high school equivalency)
03. Graduated from high school
04. Technical/vocational schooling beyond high school
05. Attended some college (but no degree)
06. Associate’s degree (2-year college degree)
07. 4-year college degree
08. Graduate or professional school beyond 4-year degree
97 DON’T KNOW
99 REFUSED
ASK if inttype=a or p
OWNRENT. Do you currently own or rent your residence?
01. OWN
02. RENT
97. DON’T KNOW
99. REFUSED
ASK if inttype=A or P
MARITAL. What is your marital status? Are you currently…
01. Married
02. Living with a partner, or have a common-law marriage
03. Widowed
04. Divorced
05. Married, but separated, or
06. Never married?
97. Don’t
know
99. Refused
ASK if inttype=a and calltype=2
LANDLINE: Do you also have a landline telephone in your home that is used to make and receive calls?
Read only if necessary: “By landline telephone, we mean a “regular” telephone in your home that is used for making or receiving calls.” Please include landline phones used for both business and personal use.”
INTERVIEWER NOTE: Telephone service over the internet counts as landline service (includes vonage, magic jack and other home-based phone services.).
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a and calltype=1
PHONES1: Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine.
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
ask if PHONES1=1
PHONES2: How many of these telephone numbers are residential numbers?
Residential telephone numbers [6 = 6 or more] RANGE=1-6
97. DON’T KNOW
99. REFUSED
ASK if inttype=a OR P and calltype=1
CELLPH: Including phones for business and personal use, do you have a cell phone for personal use?
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
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] year old [IF MALE= “son” IF FEMALE=”daughter”].”
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: ______[1-96]
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: ______[1-96]
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 adult demographics or cycle through proxy SCREENING(s)
To help us ensure that we are talking to a representative selection of households in the United States, we have just a few questions for classification purposes only.
ASK if inttype=a and INJN+INjN2>= 1
HINS. What kind(s) of health insurance do you have?
(CODE ALL THAT APPLY).
[INTERVIEWER: IF RESPONDENT GIVES A SPECIFIC PLAN NAME NOT LISTED BELOW, PROBE “Who pays for the insurance: an employer, the government, or you?” AND CODE ACCORDINGLY]
01 Private health insurance through an employer (IF NEEDED: either your own or through a spouse’s or parent's employer, either past or present)
02 Medicare (IF NEEDED: an insurance plan funded by Social Security for people who are disabled or are over age 65)
03 Medicaid (IF NEEDED: for example MediCal-California, HCCCS-Arizona, HealthWave-Kansas)
04 Federal Health Plans such as TriCare (IF NEEDED: for military personnel and families) or the VA (IF NEEDED: Veterans Administration),
05 Private health insurance or Medicare supplemental insurance that you pay for yourself, or
95 Some other insurer?
96 DON’T HAVE HEALTH INSURANCE
97 DON’T KNOW
99 REFUSED
IF CALLTYPE = 01 and CONEADLT=01 and numc>0 and ADLTS>1 and [(SELADLT=01 and infor=02) or (seladlt=02 and infor2=02) or (seladlt=01 and isparnt=02)]
SPEAKTOP. I also need to speak to a parent or guardian living in your household who knows about the health and activities of each child. May I speak to the person who knows this information?
KNOWLEDGEABLE ADULT COMING TO THE PHONE
KNOWLEDGEABLE ADULT NOT AVAILABLE [SCHEDULE CB]
IF SPEAKTOP=01 PICK UP AT CPROXY. ASK TRANS1 THROUGH CRACEA WHERE INTTYPE=P
ASk if inttype=p and (NUMC or CNUMC>1) and INJN+INjN2=0
PROXYINT
These next few questions are about your [INSERT AGE] year old [INSERT GENDER] child.
ASK if INTTYPE=P
RELATION: What is your relationship to this child?
INTERVIEWER: READ ONLY IF NECESSARY
01 Parent or legal guardian
02 Grandparent
03 Other relative
04 Non-relative
05 Other
97. DON’T KNOW
99 REFUSED
ASK if inttype=Pand INJN+INjN2 >= 1
CHINS. What kind(s) of health insurance does your child have?
(CODE ALL THAT APPLY).
[INTERVIEWER: IF RESPONDENT GIVES A SPECIFIC PLAN NAME NOT LISTED BELOW, PROBE “Who pays for the insurance: an employer, the government, or you?” AND CODE ACCORDINGLY]
01 Private health insurance through an employer (IF NEEDED: either your own or through a spouse’s or parent's employer, either past or present)
02 Other Federal Health Plans such as TriCare (IF NEEDED: for military personnel and families) or the VA (IF NEEDED: Veterans Administration),
03 Private health insurance or Medicare supplemental insurance that you pay for your child, or
95 Some other insurer?
96 DON’T HAVE HEALTH INSURANCE FOR CHILD
97 DON’T KNOW
99 REFUSED
ASK if INTTYPE= P
CHISPA. Is your child Hispanic, Latino/a, or of Spanish origin?
01. No, not Hispanic, Latino or of Spanish origin
02. Yes, Hispanic, Latino, or of Spanish origin
97. DON’T KNOW
99. REFUSED
ASK if INTTYPE= P
CRACEA. Which one or more of the following would you say is your child’s race?
INTERVIEWER: IF RESPONDENT SAYS “HISPANIC OR LATINO” SAY, “THANK YOU – I HAVE RECORDED THAT YOUR CHILD IS HISPANIC/LATINO. WOULD YOU SAY THAT YOUR CHILD IS WHITE, BLACK OR AFRICAN AMERICAN, AMERICAN INDIAN OR ALASKA NATIVE, ASIAN, NATIVE HAWAIIAN OR PACIFIC ISLANDER, OR MORE THAN ONE OF THESE?”
01 White
02 Black or African American
03 American Indian or Alaska Native
04 Asian, or
05 Native Hawaiian or other Pacific Islander
DO NOT READ
95 OTHER
97 DON’T KNOW
99 REFUSED
ASK if inttype=P and proxy age 13-17 (randomly select 1 if there is more than 1)
ADOL
Thank you so much for providing information about your [“child’s” OR “children’s”] experiences with head injuries in the past 12 months.
We would like your permission to speak to your [AGE] year old child directly to ask him or her some questions about their experience, if any, with head injuries. Allowing your child to participate in this study will add to the CDC’s knowledge about the circumstances surrounding head injuries and the groups most at risk for such injuries. There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your child’s information private, their name will never be connected with their answers. CDC will keep the information that your child provides private and secure to the extent permitted by the law.
Even if you agree now, your child may choose not to participate.
CONTINUE
ASK if inttype=P
ASKADOL
May we conduct an interview with your [AGE] year old child?
01 YES
02 NO
ASK IF ASkadol=01
SPST2. Is your child available now? If so, we can conduct the survey right now over the phone.
01 YES, AVAILABLE NOW
02 NO, NOT AVAILABLE
02. NO
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 7 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 adol1=2 or SPST2=02
ADOLCB. We can text [IF SPST2=2 READ “your child”/ IF ADOL1=2 READ “you”] a link to complete the survey online. What is [IF SPST2=2 READ “your child’s”/ IF ADOL1=2 READ “your”] cell phone number?
GIVES NUMBER
NOT INTERESTED
Ask if ADOLCB=01
TEXT
/record number:/
Ask if adolcb=02
ASKEMAIL. I can email [IF SPST2=2 READ “your child”/ IF ADOL1=2 READ “you”] a link to complete the survey online. What is [IF SPST2=2 READ “your child’s”/ IF ADOL1=2 READ “your”] email address?
GIVES EMAIL
02 NOT INTERESTED
Ask if ASKEMAIL=01
/record email/
//Ask all//
PNCLOSE. That was my last question. Thank you very much for participating in this important research study.
01 CONTINUE
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |