Follow-Up Activities for Product-Related Injuries-Interviews

Children's Poisonings

Questionnaire # ________ (1-4)

Q.1 CHILDREN'S POISONINGS QUESTIONNAIRE for CHILDREN LESS THAN 5 YEARS OLD (Last
updated March, 2019)
General Instructions:
Bold type indicates what should be said to the respondent. Instructions for the interviewer will be
prefaced by "Interviewer:" and are written in non-bold type.
Interviewer: Please do not read choices or give examples unless the respondent is unsure, then you
can prompt. Do not read the “Refused” or “Unknown” choices.

Q.2 Interviewer: Please enter the task number.
__________________________

(5-17)

Q.3 Interviewer: Please enter the incident date.
MM
DD
YY

____ (19-20)
____ (22-23)
____ (25-26)

Q.4 Contact Questions
Interviewer: Ask for the parent or guardian of the child.
Introduction: Hello, I am calling on behalf of the U.S. Consumer Product Safety Commission.
We are trying to learn more about poisonings to children to prevent incidents and injuries.
Your answers will be kept confidential. No names will be associated with the answers. The
information collected will be used only to prevent future incidents and injuries.
Are you familiar with the recent incident involving a poisoning to a child which resulted in a
visit to the emergency room on [ANSWER TO SUB-QUESTION 1 OF Q. 3]/[ANSWER TO SUBQUESTION 2 OF Q. 3]/[ANSWER TO SUB-QUESTION 3 OF Q. 3] ?
(28)

q 1 Yes
q 2 No
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 6]

2

Q.5 Could I speak to another available adult who is familiar with the recent incident?
Interviewer: If the response is yes, ask to speak to that person.
(30)

q 1 Yes
q 2 No
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 37]

Q.6 What is your relationship with the patient?
(32)

q 1 Parent
q 2 Guardian other than parent
q 3 Other
[IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 8]

Q.7 Please identify "Other" relationship.
__________________________________________________________________________________
__________________________________________________________________________________

Q.8 Do you have a few minutes to talk about the incident?
Interviewer: The interview should take about 10 minutes.
(135)

q 1 Yes
q 2 No
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 10]

(34-133)

3

Q.9 Can I call you back at a better time?
Interviewer: If response is "Yes", then record the date and time to call back.
(137)

q 1 Yes
q 2 No
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 41]
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 37]

Q.10 Did you witness the incident?
(139)

q 1 Yes
q 2 No

Q.11 Please give a brief summary of the reason for the emergency room visit:
Interviewer: If not provided by respondent, please probe for the following information:
- Where was the child when the incident occurred? (ex: kitchen, bathroom, etc.)
- Was another child involved?
- How did the child access the medication/product?
- Where was the medication/product stored?
- Was someone using the medication/product at the time of the incident?
- Had the medication/product spilled or had the packaging been damaged/broken just prior to the
exposure?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

(141-440)

4

Q.12 Please describe the symptom(s) experienced by the victim, any treatment(s), and the
outcome of the exposure.
_________________________________________________________________________________

(442-691)

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Q.13 Please describe the type of exposure that occurred in this incident.
Interviewer: Choose all that apply.
(693-697)

q1
q2
q3
q4
q5

Ingestion
Skin
Eye
Mouth (inside, not swallowed) and/or lips
Other

[IF THE ANSWER IS NOT 5, THEN SKIP TO QUESTION 15]
[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 14]

Q.14 Please describe the other type of exposure.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

(699-898)

5

Q.15 What type of product formulation was involved in the exposure?
(900)

q1
q2
q3
q4

Liquid
Pills, tablets, capsules
Other
Don't know

[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 16]
[IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 17]

Q.16 Please describe the "Other" type of formulation.
Interviewer: Other product types include transdermal patches, creams/ointments, sprays,
powders/granules, medicated lollipops, etc.
________________________________________________________________________________

(902-1051)

________________________________________________________________________________

Q.17 What is the brand name and/or manufacturer?
Interviewer: Get the information for each product ingested, possibly ingested, spilled, sprayed, etc.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

(1053-1302)

6

Q.18 How much would you estimate the child ate, drank, spilled, sprayed, etc?
Interviewer: Get the information for each product ingested, possibly ingested, or spilled/sprayed
on/in the skin, eye, etc.
_______________________________________________________________________________

(1304-1553)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Q.19 Was the product in the original container, some other kind of container, or not in any
container at all?
(1555)

q1
q2
q3
q4
q5

Original container
Daily or weekly pill holder or pill minder
Other container
No container
Don't know

[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 21]
[IF THE ANSWER IS 4, THEN SKIP TO QUESTION 25]
[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 37]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 24]

Q.20 Please describe the pill holder/pill minder.
_______________________________________________________________________________
_______________________________________________________________________________

(1557-1656)

7

Q.21 Where was the container located?
_______________________________________________________________________________

(1658-1857)

_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 19 IS 1, THEN SKIP TO QUESTION 26]
[IF THE ANSWER TO QUESTION 19 IS 3, THEN SKIP TO QUESTION 26]

Q.22 Were other medications also stored in the pill holder/minder?
(1859)

q 1 Yes
q 2 No
q 3 Don't know
[IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 37]

Q.23 Please describe the other medications in the pill holder/minder.
_______________________________________________________________________________

(1861-2010)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 22 IS 1, THEN SKIP TO QUESTION 37]

Q.24 Please describe the other container.
Interviewer: Possibilities include a plastic or paper bag, pocket, pocketbook, etc.
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 19 IS 3, THEN SKIP TO QUESTION 21]

(2012-2161)

8

Q.25 Please explain why the product was out of any container.
Interviewer: Possibilities could include product spilled, in use, left available on a countertop, an
older child accessed and gave to victim, etc.
_______________________________________________________________________________

(2163-2362)

_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 19 IS 4, THEN SKIP TO QUESTION 37]

Q.26 Was the container tightly closed, somewhat closed, or not closed at all?
(2364)

q1
q2
q3
q4

Tightly closed
Somewhat closed
Not closed at all
Don't know

Q.27 Was the package/container child-resistant, that is, one that would be hard for a child to
open?
(2366)

q 1 Yes
q 2 No
q 3 Don't know
[IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 29]

Q.28 How long was the child alone with the child-resistant container?
(2368)

q 1 Less than 10 minutes
q 2 Greater than 10 minutes
q 3 Don't know
[IF THE ANSWER TO QUESTION 15 IS NOT 1, THEN SKIP TO QUESTION 31]

9

Q.29 Earlier you indicated the product was a liquid. Did the package/container have a flowrestrictor on its opening? (A flow restrictor is a small plastic device that fits into the neck of a
medicine bottle and slows the release of the fluid.)
(2370)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER TO QUESTION 29 IS NOT 1, THEN SKIP TO QUESTION 31]

Q.30 Please describe the flow restrictor type. Could it be easily removed from the
package/container or was it permanently attached or part of the package container
opening/design? Was a syringe required to remove the medication from the container?
_______________________________________________________________________________

(2372-2621)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Q.31 Was the product a prescription medication, an over-the counter medication, a household
chemical, or some other product?
(2623)

q1
q2
q3
q4

Prescription medication
Over-the-counter medication
Household chemical
Other

[IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 33]

10

Q.32 Please describe the "Other" type of product.
_______________________________________________________________________________

(2625-2774)

_______________________________________________________________________________

Q.33 Please identify the source of the medication/product or where it was purchased (ex:
pharmacy name, retail store, etc.).
_______________________________________________________________________________

(2776-2925)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 19 IS NOT 1, THEN SKIP TO QUESTION 36]

Q.34 Do you still have the container?
(2927)

q 1 Yes
q 2 No
q 3 Don't know
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 36]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 36]

Q.35 Would you be willing to send us the container, if we mail you a shipping envelope that is selfaddressed and stamped?
Interviewer: If the answer is yes, EPDS staff should mail a form letter and a pre-addressed jiffy bag
(with the task number clearly marked on the return bag) to the victim’s family.
(2929)

q 1 Yes
q 2 No
[IF THE ANSWER TO QUESTION 27 IS NOT 2, THEN SKIP TO QUESTION 37]

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Q.36 Earlier you indicated that the the package/container was NOT child-resistant. Was non-childresistant packaging requested from the pharmacy?
(2931)

q 1 Yes
q 2 No
q 3 Don't know

Q.37 Due to the cultural diversity in the U.S., we sometimes have difficulty communicating
important product safety information to consumers. The following race and ethnicity
questions will help us to better educate the public on consumer product safety.
Do you consider the victim to be Hispanic or Latino?
(2933)

q1
q2
q3
q4

Yes
No
Unknown
Refused to answer

Q.38 What race or races do you consider the patient to be?
Interviewer: Please read race choices aloud and ask respondent to select ALL categories that
apply. If the answer is "Other" enter their answer verbatim in the next question.
(2935-2940)

q1
q2
q3
q4
q5
q6
q7
q8

White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
Other
Unknown
Refused to answer

[IF THE ANSWER IS 6, THEN SKIP TO QUESTION 39]
[IF THE ANSWER IS NOT 6, THEN SKIP TO QUESTION 40]

12

Q.39 Please specify "Other" race or races.
Interviewer: If respondent states "biracial" or "multiracial", please prompt for specifics (country of
origin, nationality, etc.). Otherwise, simply state "biracial" or "multiracial".
_______________________________________________________________________________

(2943-3017)

Q.40 On behalf of the Consumer Product Safety Commission, I thank you very much for your help.
If I missed anything, may I call you back?
(3018)

q 1 Yes
q 2 No

Q.41 Thank you for your time.

Q.42 Interviewer: Please enter the interview completion date (mmddyy):
MM
DD
YY

Q.43 Date
__________________

(3029-3037)

Q.44 Interviewer
________

(3039-3042)

Q.45 Duration of interview
____________

(3044-3049)

____ (3020-3021)
____ (3023-3024)
____ (3026-3027)