Adult Questionssaire - sample

Att9 Sample Questionnaire Adult 20200108.docx

Poison Center Collaborations for Public Health Emergencies

Adult Questionssaire - sample

OMB: 0920-1166

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Attachment 9: Sample Questionnaire – Adult












[GenIC Name]

Form Approved

OMB No. 0920-1166

Exp. Date 02/29/2020



Date of the interview: ____/____/______ Name of interviewer: _______________________

Poison center: _____________________________

State call originated from: ____________________

Title of the investigation: ____________________

NPDS Case ID No. ____________________


I. Exposure Information

Now I am going to ask you a few questions about the [exposure type] and the circumstances surrounding when you were exposed.


For consumer products or contaminated food/water


  1. What was the product name of the [source of exposure] you/your child were exposed to? (read all choices and choose one)

[name relevant to exposure]

[name relevant to exposure]

[name relevant to exposure]

Other (describe):      

Do not know

Refuse to answer

  1. Where was the product taken from when the actual exposure occurred? (read all choices and choose one)

[source relevant to exposure]

[source relevant to exposure]

[source relevant to exposure]

Other (describe):      

Do not know

Refuse to answer

  1. Where were you/your child when the exposure occurred? (read all choices and choose one)

[location relevant to exposure]

[location relevant to exposure]

[location relevant to exposure]

Other (describe):      

Do not know

Refuse to answer

CDC estimates the average public reporting burden for this collection of information as 40 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-1166).





  1. Was the [exposure] stored in the original container when you/your child were exposed?

Yes

No Go to part b

Do not know

Refuse to answer

b. If no, what was the product stored in? (read all choices and check all that apply)

[container relevant to exposure]

[container relevant to exposure]

[container relevant to exposure]

Other (describe)      

None

Do not know

Refuse to answer


  1. Did you/your child intentionally expose yourself/themselves to the product?

Yes

No

Do not know

Refuse to answer


  1. Was the product clearly labeled as to its ingredients?

Yes

No

Do not know

Refuse to answer


  1. Can you estimate how much [exposure of interest] you/your child [route of exposure]? (choose one)

[amount per source relevant to exposure]

[amount per source relevant to exposure]

[amount per source relevant to exposure]

Other (describe):      

Do not know

Refuse to answer

  1. What was the appearance of the [exposure of interest] you/your child [route of exposure]? (read all choices and choose one)

[appearance relevant to exposure]

[appearance relevant to exposure]

[appearance relevant to exposure]

Do not know

Refuse to answer

  1. What was the color of the [exposure of interest] you/your child [route of exposure]? (read all choices and choose one)

[color relevant to exposure]

[color relevant to exposure]

[color relevant to exposure]

Do not know

Refuse to answer



  1. Did the [exposure of interest] you/your child [route of exposure] have a [smell relevant to exposure]? (choose one)

Yes

No

Do not know

Refuse to answer

  1. Did the [exposure of interest] you/your child [route of exposure] have a [taste relevant to exposure]? (choose one)

Yes

No

Do not know

Refuse to answer

For natural or man-made disaster that increases risk for exposure due to a change in living conditions, available resources, or risk for contaminant exposure


  1. What were you/your child doing when you/your child began to feel ill?

     

Refuse to answer

  1. Where were you/your child when you/your child became ill due to [exposure]?

Home Go to part b

Staying with friends or family Go to part b

At a shelter

Hotel

Business

Other      

Refuse to answer

b. If you/your child were staying at your home or someone else’s home, how would you describe the house where you/your child became ill? Read aloud. Check one

Single-family house

Multiple unit house (duplex, triplex, etc.)

Apartment or condominium

Motor home or RV

Mobile home or trailer

Boat

At a shelter

Hotel

Business

Other, specify _____________________________

Do not know

Refuse to answer

  1. Did the place where you/your child became ill lose power as a result of [incident]?

Yes Go to part b No Do not know Refuse to answer

b. Approximately how many days/hours was the place you/your child became ill without power?

      days       hours Refuse to answer

  1. Do you know the source of [exposure] that caused your/your child’s illness?

Yes No Do not know Refuse to answer

For carbon monoxide poisonings


  1. What was the source or sources of your/your child’s carbon monoxide poisoning? (mark all that apply)

Generator Go to question 14

Propane Heater

Kerosene Heater

Propane grill

Charcoal grill

Propane camp stove

Woodstove

Fireplace (wood or natural gas)

Boiler (oil)

Boiler (natural gas)

Furnace (oil)

Furnace (natural gas)

Hot Water Heater (oil)

Hot Water Heater (natural gas)

Gas Oven

Gas Stove

Kerosene Lamp(s)

Fire

Vehicle

Other      

Do not know

Refuse to answer

Unless the respondent answered “Generator” in the above question, go to the next section.



  1. Where was the generator placed while running?

Outside (outdoors means outside of any enclosure) SELECT ONE

Outside, <20ft from house (less than 2-car lengths away)

If YES, was the generator near an open or broken window/door? Yes No

Outside, at least 20 feet from house (or at least 2 car-lengths away)

Inside SELECT ONE

Inside the living space in a room with all doors and windows closed (includes basement)

Inside the living space in a room with at least one window open

Inside an attached garage with garage door open

Inside an attached garage with garage door closed

Inside an enclosed porch

In detached garage, shed, outbuilding

If so how far from house

<10 feet (approximately 1 car length)

10 feet to <20 feet

20 or more feet

In another location      

Do not know

Refuse to answer

  1. How many days was the generator used before you/your child became ill?

Less than one day

For one day

Between one and three days

Between three and seven days (one week)

More than one week

Other      

Do not know

Refuse to answer

  1. What were you using the generator to power? (check all that apply)

Heat

Hot Water

Television

Radio

Lights

Refrigerator or freezer

Power equipment or tools

Medical equipment

Other (specify)      

Do not know
Refuse to answer







II. Health Effects and Medical Treatment

Now I am going to ask you a few questions about the health effects and medical treatment caused by [exposure].


  1. I am going to read a list of symptoms that you/your child may have had after [the exposure]. Please tell me if you/your child had any of the following symptoms between [time period] (choose all that apply)

[symptom]

[symptom]

[symptom]

[symptom]

[symptom]

Other symptom

Other symptom

Other symptom

Do not know

Refuse to answer

None


  1. What did you do when you thought there was a problem? (check all that apply)

Called for help

Poison Control

Doctors Office

911 / EMS

Other      

Open windows and waited to see if symptoms decrease

Left house to see if symptoms decreased

Tried to turn off the suspected cause and waited to see if symptoms would improve

Went immediately to doctors or hospital to get help

Did not suspect there was a problem or didn’t know what the problem was

Other      

Refuse to answer

  1. What was the reason for your call to the Poison Center during or immediately after [incident of interest]? (check all that apply)

Wanted information about [exposure]

Worried about being exposed to [exposure]/Worried about child being exposed to [exposure]

Was feeling ill/Child was feeling ill

Know exposed to [exposure]/Know child exposed to [exposure]

Smelled something

Other (describe):      

Refuse to answer

  1. What action did the poison center recommend? (please describe in detail)

     

Refuse to answer

  1. Did you/your child go to any kind of healthcare facility such as a doctor’s office, emergency room or urgent care center after your/your child’s [exposure]? (choose one)

Yes Go to part b

No Go to next section

Do not know

Refuse to answer


b. What type of healthcare facility did you/your child go to? (choose the initial one the patient went to)

Hospital Emergency Room

Pediatrician’s Office

Urgent Care Center

Other (describe)      

Do not know

Refuse to answer


  1. What kind of treatment did you/your child receive while in the healthcare facility? (read all choices and check all that apply)

[treatment relevant to exposure]

[treatment relevant to exposure]

[treatment relevant to exposure]

[treatment relevant to exposure]

[treatment relevant to exposure]

Other (describe)      

Do not know

None

Refuse to answer


  1. What kind of procedures did you/your child receive in the healthcare facility? (read all choices and check all that apply)

[procedure relevant to exposure]

[procedure relevant to exposure]

[procedure relevant to exposure]

[procedure relevant to exposure]

Other (describe)      

Do not know

None

Refuse to answer


  1. Did a doctor place you/your child on any medications as a result of this illness? (choose one)

Yes Go to part b

No

Do not know

Refuse to answer




b. If yes, which medications? (read all choices and check all that apply)

[medication relevant to exposure]

[medication relevant to exposure]

Other (describe)      

None

Do not know

Refuse to answer


  1. After the visit at the health care facility was completed, what happened?

Discharged

Admitted

Transferred/transported to other healthcare facility (specify)      

Other (describe)      

Do not know

Refuse to answer


III. Health Messaging

We are almost finished. The last few questions are about what you have heard regarding the [exposure].


  1. Immediately before or during the [incident], did you hear or read warnings about the danger of [exposure]?

Yes Go to part b

No

Do not know

Refuse to answer

b. If so where did you hear or read these warnings?

Newspapers/magazines

Pamphlet/fact sheet

Fire Department

Radio

Television

Friends or family

Salesman or store employee

Law enforcement

Utility workers

Other      

Do not know

Refuse to answer









  1. Did you hear any communication messages prior to [exposure]? (Health alerts, evacuation orders, radio alerts, etc.)

[messages relevant to exposure] Go to part b

[messages relevant to exposure] Go to part b

[messages relevant to exposure] Go to part b

Other (describe):       Go to part b

No

Do not know

Refuse to answer

b. Did you act upon those communication messages?

Yes

No

Do not know

Refuse to answer

  1. What exposure prevention methods were in place prior to the exposure? (e.g., CO detector for CO exposure, child-resistant caps for lamp oil)

[messages relevant to exposure]

[messages relevant to exposure]

[messages relevant to exposure]

Other (describe):      

Do not know

Refuse to answer

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