DATE
Attachment 10: Sample Questionnaire – Adolescent
[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
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
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
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). |
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
Did you/your child intentionally expose yourself/themselves to the product?
Yes
No
Do not know
Refuse to answer
Was the product clearly labeled as to its ingredients?
Yes
No
Do not know
Refuse to answer
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
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
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
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
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
What were you/your child doing when you/your child began to feel ill?
Refuse to answer
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
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
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
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.
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
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
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].
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
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
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
What action did the poison center recommend? (please describe in detail)
Refuse to answer
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
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
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
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
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].
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
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
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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |