Dataset for Questionnaire - example
Att14 Example Dataset for Questionnaire.xlsx
Poison Center Collaborations for Public Health Emergencies
Dataset for Questionnaire - example
OMB: 0920-1166
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1166 can be found here:
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ID |
DateInterview |
InterviewerID |
PoisonCenterID |
State |
NpdsCaseID |
Q1Name1 |
Q1Name2 |
Q1Name3 |
Q2Source1 |
Q2Source2 |
Q2Source3 |
Q3Location1 |
Q3Location2 |
Q3Location3 |
Q4 |
Q4b |
Q5 |
Q6 |
Q7 |
Q8 |
Q9 |
Q10 |
Q11 |
Q12 |
Q13 |
Q13b |
Q14 |
Q14b |
Q15 |
Q16generator |
Q16PropaneHeater |
Q16KeroseneHeater |
Q16PropaneGrill |
Q16CharcoalGrill |
Q16PropaneCampStove |
Q16Woodstove |
Q16Fireplace |
Q16BoilerOil |
Q16BoilerNG |
Q16FurnaceOil |
Q16FurnaceNG |
Q16HotWaterHeaterOil |
Q16HotWaterHeaterNG |
Q16gasOver |
Q16GasStove |
Q16KeroseneLamp |
Q16Fire |
Q16Vehicle |
Q16Other |
Q16DNK |
Q16Refuse |
Q17 |
Q17Outside |
Q17Inside |
Q18 |
Q19Heat |
Q19HotWater |
Q19Television |
Q19Radio |
Q19Lights |
Q19refrigerator |
Q19Power |
Q19Medical |
Q19Other |
Q19DNK |
Q19Refuse |
Q20Symptom1 |
Q20Symptom2 |
Q20Symptom3 |
Q20DNK |
Q20Refuse |
Q20None |
Q21Call |
Q21PoisonCenter |
Q21Doctor |
Q21EMS |
Q21Windows |
Q21Left |
Q21TurnOff |
Q21Hospital |
Q21NoProblem |
Q21Other |
Q21Refuse |
Q22Information |
Q22Exposure |
Q22Ill |
Q22KnownExposure |
Q22Smell |
S22Other |
Q22Refuse |
Q23 |
Q24 |
Q24b |
Q25Treatment1 |
Q25Treatment2 |
Q25Treatment3 |
Q25Other |
Q25DNK |
Q25None |
Q25Refuse |
Q26Procedure1 |
Q26Procedure2 |
Q26Procedure3 |
Q26Other |
Q26DNK |
Q26None |
Q26Refuse |
Q27 |
Q27b |
Q28 |
Q29 |
Q29b |
Q30 |
Q30b |
Q31 |
1 |
8/8/2016 |
1 |
23 |
GA |
12345 |
1 |
0 |
0 |
0 |
0 |
1 |
1 |
0 |
0 |
Y |
NA |
N |
Y |
DNK |
Skinny vial |
Red |
Y |
N |
TV |
Home |
Single Family |
Y |
12 |
Y |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Outside |
<20ft |
NA |
One day |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
ER |
Y |
ER |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
Y |
DNK |
Discharged |
Y |
Radio |
DNK |
N |
Evacuate |
2 |
8/9/2016 |
2 |
23 |
GA |
12346 |
0 |
1 |
0 |
0 |
0 |
1 |
0 |
1 |
0 |
N |
DNK |
N |
Y |
Refuse |
bottle |
Green |
Y |
Y |
Sleeping |
hotel |
NA |
N |
NA |
Y |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Inside |
NA |
Enclosed porch |
One day |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
home |
N |
NA |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
N |
NA |
NA |
N |
NA |
N |
N |
DNK |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |