Follow-Up Activities for Product-Related Injuries-Interviews

Self-Administered E-Scooters
Survey Flow
Standard: Start Block (1 Question)
Authenticator: Single Sign On - Token
EmbeddedData
ExternalDataRefernceValue will be set from Panel or URL.
hospnameValue will be set from Panel or URL.
injurydateValue will be set from Panel or URL.
passwordValue will be set from Panel or URL.
tknoValue will be set from Panel or URL.
Standard: Introductory Block (5 Questions)
Standard: Item Verification Block (11 Questions)
Standard: Incident Block (12 Questions)
Standard: Scooter Characteristics Block (13 Questions)
Standard: Closing Block (9 Questions)
Page Break

Page 1 of 17

Start of Block: Start Block
Q1 The U.S. Consumer Product Safety Commission (CPSC) collects data through the National
Electronic Injury Surveillance System (NEISS) on injuries treated in hospital emergency
departments. CPSC conducts follow-up investigations with a small number of people to learn
more about how the injury occured. The results of these investigations will be used to determine
if similar injuries can be prevented in the future.
Your participation in this survey is completely voluntary and your identity and answers will be
strictly confidential. This survey will take between 10-15 minutes and data are used for
statistical purposes only.
You should have received a letter with the following information needed to continue:
1. Investigation Task Number
2. Randomly generated password
To continue, you will have to enter the task number correctly below:
End of Block: Start Block
Start of Block: Introductory Block
I1
CPSC would prefer that the person who answers this questionnaire is the actual person injured
and treated in the hospital emergency department. If the injured person is under the age of 16,
CPSC would prefer that a parent or guardian completes the questionnaire.
Was the injured person 16 years old or older?
Note: If you are the injured person and are under 16, please ask your parent or guardian to
complete the survey. If no one is available, it is okay to respond yourself.

o Yes (1)
o No (2)

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I2 According to our records from the National Electronic Injury Surveillance System the injured
person was seen on ${e://Field/injurydate} in the emergency department at
${e://Field/hospname} for an injury that involved a scooter. Is that correct?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: End of Block If I2 = Don't know
Skip To: End of Block If I2 = Yes

I3 What information is incorrect from the statement above?

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Different date (1)
Different hospital (2)

(I/the victim) did not receive treatment in a hospital emergency department for a
scooter injury (3)

Skip To: End of Survey If I3 = (I/the victim) did not receive treatment in a hospital emergency department
for a scooter injury
Display This Question:
If I3 = Different date

I4 What is the correct date?
________________________________________________________________

Display This Question:
If I3 = Different hospital

I5 Where did you/the victim receive treatment for your/their injury?
________________________________________________________________

Page 3 of 17

End of Block: Introductory Block
Start of Block: Item Verification Block
V1 Are you the:

o Injured person (1)
o Parent or guardian of injured person (2)
o Other (specify in next window) (3)
Skip To: V3 If V1 = Injured person
Skip To: V3 If V1 = Parent or guardian of injured person
Display This Question:
If V1 = Other (specify in next window)

V2 Specify relationship:
________________________________________________________________

Display This Question:
If V1 = Injured person
Or V1 = Parent or guardian of injured person
Or Specify relationship: Text Response Is Not Empty

V3 Was the scooter unpowered (e.g., a kick scooter or push scooter)?
Note: Powered scooters have a power source like electric or gas. Below is an example of an
unpowered scooter.

o Yes (1)
o No (2)
o Don't know (4)
Page 4 of 17

Skip To: V10 If V3 = Yes
Display This Question:
If V3 = No
Or V3 = Don't know

V4 Was the scooter an assisted mobility scooter to help people with physical limitations?
Note: Below is an example of a mobility scooter.

o Yes (1)
o No (2)
Skip To: End of Block If V4 = Yes

V5 Was the scooter a moped, motorcycle, or scooter that requires a registration or license?
Note: Below is an example of a scooter that requires a registration or license.

o Yes (1)
o No (2)
Skip To: End of Block If V5 = Yes

V6 Did the scooter have handles for steering?
Note: Handles for steering are distinct from handles used for balancing purposes. Below is an
example of a scooter that has handles for steering.

Page 5 of 17

o Yes (8)
o No (9)
Skip To: End of Block If V6 = No

V7 If your scooter had only two wheels, were those wheels side-by-side?
Note: side-by-side wheels are distinct from wheels that are one in front of the other. Below is an
example of side-by-side wheels.

o Yes (1)
o No (2)
Skip To: End of Block If V7 = Yes

V8 What kind of power did the scooter run on?

o Gas (1)
o Electric (2)
o Other (specify in next window) (3)
Skip To: V10 If V8 = Gas
Skip To: V10 If V8 = Electric
Display This Question:
If V8 = Other (specify in next window)

V9 Specify.
________________________________________________________________

Page 6 of 17

V10 You/the victim were/was:

Interviewer instruction: If two scooters collided select "Riding the scooter."

o Riding the scooter (1)
o Struck by scooter (2)
o Other (specify) (3)
Skip To: End of Block If V10 = Riding the scooter
Skip To: End of Block If V10 = Struck by scooter

V11 Specify.
________________________________________________________________
Skip To: End of Block If V11 Is Not Empty

End of Block: Item Verification Block
Start of Block: Incident Block
A1 Please describe how the accident happened. That is, what were you/the victim doing just
before, during, and just after the injury occurred? Please specify the location of the accident and
any environmental factors; such as weather, temperature, and anything else that may have
contributed to the accident.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page 7 of 17

Display This Question:
If If Please describe how the accident happened. That is, what were you/the victim doing just before,
d... Text Response Is Not Empty
And If
V4 = No
And V5 = No
And V6 = Yes
And V7 = No

A2 The following are specific questions about the incident that you may have already described.
Please bear with us as you fill out the next set of questions.

Display This Question:
If A2 Is Displayed

A3 What type of surface were you/the victim on?

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Paved Road (1)
Paved Sidewalk (2)
Gravel (3)
Grass (4)
Driveway (5)
Other (specify in next window) (6)
Don't know (7)

Display This Question:
If A3 = Other (specify in next window)

A4 Specify.
________________________________________________________________

Page 8 of 17

Display This Question:
If A2 Is Displayed

A5 Was it dark or difficult to see?

o Yes (1)
o No (2)
o Don't know (3)
Display This Question:
If A2 Is Displayed

A6 Was there anything else occurring at the time of the accident such as music, cell phone
interference, or loud music?

o Yes (1)
o No (2)
o Don't know (3)
Display This Question:
If A6 = Yes

A7 Please specify the additional factors.
________________________________________________________________

Display This Question:
If V10 = Riding the scooter
And A2 Is Displayed

Page 9 of 17

A8 Were/was you/the victim carrying or holding something such as a bag, purse, or backpack?

o Yes (1)
o No (2)
o Don't know (3)
Display This Question:
If A8 = Yes

A9 What were/was you/the victim carrying?
________________________________________________________________

Display This Question:
If V10 = Struck by scooter
And A2 Is Displayed

A10 Which of the following best describes how you were injured?

o Hit from the front (1)
o Hit from the side (2)
o Hit from behind (3)
o Other (specify in next window) (4)
o Don't know (5)
Display This Question:
If A10 = Other (specify in next window)

A11 Specify.
________________________________________________________________

Page 10 of 17

Display This Question:
If V10 = Struck by scooter
And A2 Is Displayed

A12 Was there any warning before you/the victim were/was hit? (ex. bell, shouting, or other
noise)

o Yes (1)
o No (2)
o Don't know (3)
End of Block: Incident Block
Start of Block: Scooter Characteristics Block
Display This Question:
If A2 Is Displayed

S1 Which of the following best describes the scooter?

o Rental (1)
o Owned by victim (2)
o Borrowed (3)
o Other (specify in next window) (4)
o Don't know (5)
Display This Question:
If S1 = Other (specify in next window)

S2 Specify.
________________________________________________________________

Page 11 of 17

Display This Question:
If S1 = Rental

S3 Who was the scooter rented from?
________________________________________________________________

Display This Question:
If S1 = Borrowed
Or S1 = Owned by victim
Or Specify. Text Response Is Not Empty
Or Who was the scooter rented from? Text Response Is Not Empty
Or S1 = Don't know

S4 Do you know the brand and model names of the scooter or have a photo of the scooter
involved in the injury?

o Yes (1)
o No (2)
Skip To: S8 If S4 = No
Display This Question:
If A2 Is Displayed

S5 Specify brand
________________________________________________________________

Display This Question:
If A2 Is Displayed

S6 Specify model

Note: if brand is known but model is not, enter unknown below
________________________________________________________________

Page 12 of 17

Display This Question:
If A2 Is Displayed

S7 If you are able, please upload a photo of the scooter.
Skip To: S12 If S7() Is Displayed
Display This Question:
If A2 Is Displayed

S8 It is very important for us to know what brands are involved in these injuries. Would you be
willing to go look at the scooter and record the brand name, model name, and take a photo of
the scooter?
Note: You may also upload a pre-existing photo of the scooter if you have one. Select 'Yes' if
you have a pre-existing photo.

o Yes (1)
o No (2)
Skip To: S12 If S8 = No
Display This Question:
If A2 Is Displayed

S9 Specify brand
________________________________________________________________

Display This Question:
If A2 Is Displayed

S10 Specify model

Page 13 of 17

Note: if brand is known but model is not, enter unknown below
________________________________________________________________

Display This Question:
If A2 Is Displayed

S11 If you are able, please upload a photo of the scooter.

Display This Question:
If S11 Is Displayed
Or S4 = Yes
Or S8 = No

S12 Were/was you/the victim wearing any of these at the time of the incident. (Select all that
apply)

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Helmet (1)
Knee pads (2)
Elbow pads (3)
Wrist pads (4)
Reflective vest (5)
Blinking lights/Head lamp (6)
Other (specify in next window) (7)
None of the above (8)

Display This Question:
If S12 = Other (specify in next window)

Page 14 of 17

S13 Specify.
________________________________________________________________
End of Block: Scooter Characteristics Block
Start of Block: Closing Block
Display This Question:
If A2 Is Displayed

C1 Is there anything else about this accident or the scooter involved that you would like to
share?

o Yes (1)
o No (2)
Display This Question:
If C1 = Yes

C2 Explain.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

C3 The following race and ethnicity questions will help the U.S. Consumer Product Safety
Commission better focus outreach and education efforts related to e-scooter safety.

Page 15 of 17

C4 Are you/the victim Hispanic or Latino?

o Yes (1)
o No (2)
o Don't know (3)
o Prefer not to answer (4)
C5 What race(s) do you consider yourself to be? Please check all that apply.

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White (1)
Black or African American (2)
American Indian or Alaska Native (3)
Asian (4)
Native Hawaiian or Pacific Islander (5)
Other (6)
Don't Know (7)
Prefer not to answer (8)

Display This Question:
If C5 = Other

C6 Please specify "Other" race. Please be as specific as possible.
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page 16 of 17

________________________________________________________________
________________________________________________________________

Display This Question:
If A2 Is Displayed

C7 We may be interested in sending a CPSC investigator to your home to gather more
information about how the accident occurred and take more detailed pictures of the scooter.
This investigation would be set up at your convenience. May we have an investigator contact
you by phone to setup a visit?

o Yes (1)
o No (2)
Skip To: End of Survey If C7 = No
Display This Question:
If C7 = Yes

C8 Please supply your phone number.
________________________________________________________________

Display This Question:
If C7 = Yes

C9 When is a good time to call? (Check all that apply.)

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Morning (1)
Afternoon (2)
Evening (3)

End of Block: Closing Block

Page 17 of 17