Survey on Usage and Functionality of Smoke Alarms and Carbon Monoxide Alarms (SCOA) in US Households In-Home Administration

Appendix G: In-Home Survey – Consumer Product Safety Commission (CPSC)
Survey on Usage and Functionality of Smoke Alarms and Carbon Monoxide
Alarms in Households
2019 U.S. Consumer Product Safety Commission (CPSC) Survey on Usage and Functionality of Smoke and Carbon
Monoxide (CO) Detectors in Households
Door to Door Campaign 60-minute Instrument (Households with Smoke and/or CO Alarms)
Final Questionnaire
This is the In-home survey instrument that is to be administered to participants in person. The instrument features
both questions to be asked of the participant and clearly labeled instructions for the interviewers.
[MODULE 1: APPROACHING HOUSEHOLDS - QUESTIONS FOR INTERIVEWERS TO FILL]
[ASK ALL:]
S.1
What is the type of home in which the resident resides? {1a}

1
2
3
4
5
6

Single Family Detached Housing
Single Family Attached Housing (e.g., townhouse, rowhouse)
Apartment/Condo [If Apartment see Instructions for Apartment Selection]
Mobile/Other Manufactured Housing
Trailer/RV
Other (specify) [Textbox]

[IF APARTMENT (S.1=3) CONTINUE TO S.3, ELSE SKIP TO S.4]
[Interviewer Instructions] For selection of the first apartment household within an apartment/condo building or
complex, please reference the training on “Instructions for Apartment Selection.”
[Interviewer Instructions]
The following script is to be read in the instances where there is a front desk concierge. If there is no front desk
concierge present continue to apartment door.
“Good Morning/Afternoon/Evening. I am conducting research on behalf of the National Fire Protection Association
(NFPA). Part of our research requires us to interview residents of this building. I can offer them free carbon
monoxide and smoke alarm testing. Would it be ok for us to offer your residents this free service?“
Show front desk staff your Field Interviewer identification and provide them with an official letter/factsheet for
validation.
[ASK IF APARTMENT, S.1=3]
S.2 [Observe:] Do you have permission to enter the building? {1b}

1
2
3

Yes (CONTINUE)
No (SKIP TO REASON FOR TERMINATION Q.108)
Permission not needed (CONTINUE)

[Interviewer Instructions]
Start screening process before knocking on the door (Complete questions S.1 – S.2)
Once contact has been made with the resident, interviewers should immediately begin collecting information from
the respondent.

•

Interviewers should be thoroughly familiar with the scripted content below to the
extent that you can engage in a conversational style. Scripted content shown in italics.

Important — Addressing non-response to questions: Response options to questions may include “Don’t know”,
“Unsure”, or “Refused” options. Do not read these aloud at any time during the interview.
•
•

Only record these options if the respondent provides it him or herself.
If the respondent indicates that they don’t know the answer to a question, mark the appropriate answer
or fill in “DK” for Don’t Know in the space provided.

Questions marked (Observe) are for interviewers to fill in themselves. Do not read to participants.

[ASK ALL:]
S.3
Interviewer: Please complete the required team information {I}
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Unique ID (Format: YYYYMMDDHHMM) [Textbox]
Date of visit [Textbox]
Survey Interviewer name [Textbox]
Alarm Inspector name [Textbox]
Partnering Organization/ Fire Department [Textbox]
Street address [Textbox]
Apt/ Suite [Textbox]
City [Textbox]
State [Textbox]
Zip code [Textbox]
Pre-screen Start time (hh:mm) [textbox]

S.4 [Observe:] Did someone answer the door at the participant’s household? {1c}

1
2

Yes (CONTINUE)
No (SKIP TO REASON FOR TERMINATION Q.108)

[MODULE 2: INTRODUCTION]
[Interviewer Instructions]
Use the following options to get in the door – alter as applicable.
[READ:] “Hello. I am [Surveyor name piped in] and this is [Alarm Specialist name piped in] from [Fire
department/Organization piped in].

Show the participant the organization or EurekaFacts provided ID badge. Have copies of letters endorsing the
survey from CPSC and local fire department if available to share when needed.
[READ:] “Good Morning/Afternoon/Evening. I am a here on behalf of the National Fire Protection Association, or
NFPA, as part of a survey about household smoke detectors. This is a nationwide effort along with the U.S.
Consumer Product Safety Commission (CPSC) to improve home safety. We are in your neighborhood today offering
smoke alarm and carbon monoxide detector testing and replacements if needed for free!
[If needed:] Just for simplicity, I will refer to the sponsor of the survey as NFPA.
S.6

Are you the head of the household and over 18 years of age? {2a}

1
2

Yes (SKIP TO S.10)
No (CONTINUE)

[ASK IF S.6=2]
S.7
Is there another person available we may speak with, who is 18 years or older and may be considered one
of the heads of the household? {2b}

1
2

Yes (CONTINUE)
No (SKIP TO REASON FOR TERMINATION Q.108)

NO QUESTIONS S.8-S.9
[Read:] “We are asking people in your community a few questions about their smoke and carbon monoxide
detectors and doing some simple tests to make sure the detectors work. If the batteries in your detector need to be
replaced, we have new batteries to give out, free of charge. Also, if any of your detectors do not work, we have new
ones to replace them, again free of charge. We would like to collect any detectors that don’t work and send them
to the Consumer Product Safety Commission’s lab to find out why they don’t work. This interview will take up no
more than 60 minutes, and at the end of the interview we will provide you with a $50 gift card as appreciation for
your time.”
[ASK IF S.6=1 OR S.7=1]
S.10
Would you like to see if you qualify for this opportunity? Remember if you qualify, we will replace the
batteries and/or alarms as needed and you will receive a $50 visa gift card as a thank you for your time.
{New}

1
2

Yes, I want to see if I qualify (SKIP TO S.13)
No, I do not want to check my qualification

[ASK IF S.10=2]
S.11
Refusal Aversion:
Interviewer Instructions: Select and read the following refusal aversion prompts below. Attempt multiple
combinations and find the approach that works best for you. [Programming note: Select all that apply]
1.

We cannot complete this important safety campaign without the help of community members
like you. Your input is urgently needed. [Can we count on your participation?]

2.

This survey on home fire and carbon monoxide safety is the first of its kind in over 25 years. Now
is a unique opportunity for you to represent the voice of your community in this important public

safety campaign. [Can we count on your participation?]
3.

Do you happen to know someone impacted by a fire in their home in the last few years? [Wait for
response] I am sorry to hear that. Unfortunately, they are not alone. Household fires strike 1.3
million homes each year [If “no” Redirect to Fire Fact Below] [Can we count on your
participation?] [Can we count on your participation?]

4.

Did you happen to know that around the U.S. there are 1.3 million household fires and more than
$10 billion dollars in losses each year? This survey, that could benefit from your input, and from
others like you, is vital to reducing this kind of loss and tragedy. [Can we count on your
participation?]

5.

Did you happen to know that 3 out of 5 home fire deaths involve missing or malfunctioning smoke
detectors? At the same time … the risk of death in a home fire is 54% lower in homes with
working smoke alarms. Your participation today will help the U.S. Consumer Product Safety
Commission improve home safety and save lives. [Can we count on your participation?]

[ASK IF S.10=2]
S.12
[Observe:] Was/were the prompts successful? {New}

1
2

Yes, participant wants to see if they qualify (CONTINUE)
No, participant does not want to check qualification (SKIP TO REASON FOR
TERMINATION Q.108)

[ASK IF S.12=1]
S.13
Thank you, may I please have your name? {New}

1

[Textbox]

[ASK ALL:].
S.14
[COVID SCREENING QUESTIONS:] Before we continue it’s important that I ask a few quick questions
regarding COVID-19. In the past 14 days, has anyone within the household had a fever, cough or shortness
of breath? Has anyone come in contact with someone known to have COVID-19 or in contact with a person
currently waiting for a COVID-19 test result? Lastly, has anyone in the household had contact with an
individual who is currently quarantined due to COVID-19 infection?
[Interviewer Instructions]
If participant says “yes” to any of these questions, terminate the session. Thank the participant for their willingness
to participate but decline to continue.
[READ:] Thank you for your willingness to participate in our study, but just to be cautious we will not be able to
complete the interview. This is for the safety of the interview and research team and for other residents we will
encounter. Thank you for understanding. Have a good day.

1
2

Yes to any (SKIP TO REASON FOR TERMINATION Q.108)
No to all (CONTINUE TO MAIN SCREENING S.15)

[MODULE 3: SMOKE ALARM/CO DETECTOR SCREENING]
“Great. Let’s begin.”

[ASK ALL:].
S.15
First, do you have any smoke detectors in your home? When considering whether you do, please do not
include any uninhabited outbuildings or apartment hallways. If you are not sure, I can assist by inspecting
the home with you. {4a, 4a1}
[DO NOT READ]

1
2

Yes, I have smoke detectors (CONTINUE)
No, I do not have smoke detectors (SKIP TO S.19)

[ASK IF S.15=1]
S.16
Are any of your smoke detectors connected to a central alarm or security system that notifies the police
or fire department when it goes off? {4b}
[If needed: “What we mean by this is if the smoke detector detected smoke, it would automatically notify
the police or fire department.”]
[DO NOT READ LIST]

1
2
3

Yes (SKIP TO S.19)
No (SKIP TO S.19)
Don’t Know (CONTINUE)

[ASK IF S.16 “DON’T KNOW”, S.16=3:].
S.17
Thinking of all fire and smoke related incidents at your residence, has the police or fire department ever
arrived in response to a notification from a central alarm or security system? {4c}
[DO NOT READ LIST]

1
2
3

Yes
No
Never had a fire or smoke related incident

NO QUESTION S.18
[ASK ALL:]
S.19
Do you have any carbon monoxide detectors in your home? When considering whether you do, please do
not include any uninhabited outbuildings or apartment hallways. If you are not sure, I can assist by
inspecting the home with you. {5a,5a1}
[DO NOT READ LIST]

1
2

Yes, I have CO detectors (CONTINUE)
No, I do not have CO detectors (SKIP TO S.23)

[ASK IF S.19=1:].
S.20
Are any of your carbon monoxide detectors connected to a central alarm or security system that notifies
the police or fire department when it goes off? {5b}
[If needed: What we mean by this is if the carbon monoxide detector detected carbon monoxide, it would
automatically notify the police or fire department.]
[DO NOT READ LIST]

1
2
3

Yes (SKIP TO S.23)
No (SKIP TO S.23)
Don’t Know (CONTINUE)

[ASK IF S.20 “DON’T KNOW”, S.20=3:].
S.21
Thinking of all carbon monoxide related incidents at your residence, has the police or fire department
ever arrived in response to a notification from a central alarm or security system? {5c}
[DO NOT READ LIST]

1
2
3

Yes
No
Never had a carbon monoxide related incident

[ASK ALL]
S.23
[OBSERVE:] Time screening ended: ___ (hh:mm AM/PM)
Go to Abbreviated Survey for Participants without Detectors or with Detectors Connected to a Security Alarm
System if there are any combinations that indicate that the interviewer is unable to inspect either a smoke or CO
detector. See Appendix I for full list of combinations.
[ASK ALL QUALIFIED PARTICIPANTS:]
S.24
“Great you qualify for this interview! Before we begin, we need you to review a consent form with
information about the study.”
“Please read the following off of my tablet. If you agree to allow this interview to proceed, please sign the
bottom. Let me know you have any questions.”
[Interviewer Instructions]
o Go to the next page and hand the tablet to the respondent for them to read and sign
electronically.
o If participant refuses, say thank you and terminate.
[ASK ALL]
S.25
Consumer Product Safety Commission (CPSC) Survey on Usage and Functionality of Smoke Detectors
and Carbon Monoxide Detectors in Households
Informed Consent Form
Thank you for your interest in participating in the research study. This study is conducted by EurekaFacts on behalf
of the National Fire Protection Association (NFPA) and the U.S Consumer Product Safety Commission (CPSC). We
are conducting a nationwide survey on household fire and carbon monoxide (CO) safety. The purpose of this study
is to gather information about the functionality of smoke detectors and CO detectors in U.S. households by asking
a series of survey questions and testing your household smoke and CO alarms. Findings from this research will help
the NFPA and CPSC improve home safety.
The combined survey and testing of smoke alarms and CO alarms will take up to 60 minutes. Our trained and
qualified two-member survey team will ask you questions related to your smoke detectors and CO detectors, and
then inspect these devices in your home. You will receive a $50 gift card from a major card company as a token of
appreciation for completion of the study.

If the survey team finds any detectors to be non-functioning, new detectors and/or batteries can be offered, free
of charge, based on availability. If you are renting your home, the property manager will need to be contacted to
arrange installation of the new detector at a later date. With your permission, we would like to collect nonfunctioning smoke or CO detectors and send them to CPSC’s lab to find out why they don’t work. In addition, we
may request your permission to take a photograph of your smoke and CO detector(s) to study different alarm
types and functionalities.
Information collected from this study will help the NFPA and CPSC to improve household fire and CO safety Your
input will assist with developing standards and guidelines that will help protect property and human life. This
research does not involve any foreseeable risks.
Your participation in this research study is completely voluntary. You may stop at any time if you do not want to
continue with the study by notifying a member of the survey team. Your responses will be maintained confidential
and will be used for research purposes only. At no time will any identifiable information be linked to any of your
answers. All information collected through our research process is reported to the NFPA and CPSC anonymously.
S.25a

We ask for your consent to participate in answering questions as part of the survey portion of this study.
1
2

I consent
I do not consent (SKIP TO REASON FOR TERMINATION Q.108)

S.25b We ask for your consent to participate in the smoke and CO alarm testing portion of this study in your
home.
1
2
S.25c

I consent
I do not consent (SKIP TO REASON FOR TERMINATION Q.108)

Your signature below means that you have freely agreed to participate in this research study. You should
consent only if you have read this document and you understand its contents. {2d}

[ASK ALL]
S.26
Informed Consent Form {2e-eg}
a
b
c

Signature [Signature box]
Enter Name [Text box]
Date [Textbox]

(READ) “Thank you. It is also important that you read and sign a hold harmless agreement for our visit to your
house today.

[Interviewer: Read the information below if the participant requires additional information.]
*This form generally indicates that the occupant or owner of the property agrees to waive his or her rights
to sue any individual, any municipality and any other organizations or individuals involved in the safety inspection
of this home, if a fire or increased levels of carbon monoxide occurs after the inspection. The purpose of the
waiver is to protect the individual or any of the organizations involved against liability arising from the home fire
inspection. This statement is intended for information only, the terms of the waiver themselves shall prevail if
there are any questions. You should seek advice if you do not understand this waiver.

[ASK ALL:]
S.27
Waiver, Release and Hold Harmless Agreement {Q48}
In consideration of the voluntary performance of my participation in the National Fire Protections
Association (NFPA) and U.S. Consumer Product Safety Commission (CPSC) Survey on Usage and
Functionality of Smoke Detectors and Carbon Monoxide Detectors in Households, which is being
conducted at my residence, located at
I, on behalf of myself, and all members of family, as well as my heirs, executors, administrators or
successors, hereby waive any claim or cause of action of any nature that I have, or in the future may have, against
any and all individual or organizational participants in the CPSC Survey on Usage and Functionality of Smoke
Detectors and Carbon Monoxide Detectors in Households, including but not limited to the NFPA, CPSC, and
EurekaFacts, LLC, its agents or employees, which claim or cause of action grows out of or results from increased
levels of carbon monoxide, a fire or other damage, following the testing and inspection of one or more of the
smoke and or carbon monoxide detectors, in addition one or more of the following action(s):

1)
2)
3)
4)
5)
6)
7)

Replaced batteries
Provided new smoke detector(s)
Collected faulty smoke detector(s)
Obtained photograph of smoke/ carbon monoxide detector(s) (Device only)
Provided new CO detector(s)
Collected faulty CO detector(s)
The possibility of no additional action

I further hereby agree to release and hold harmless any and all organizational and individual participants
including the [Partner Name] and municipality of [MUNICIPALITY NAME] in the NFPA and CPSC Survey on
Usage and Functionality of Smoke Detectors and Carbon Monoxide Detectors in Households from and
against all damages of any kind, to persons or property, growing out of or resulting from a fire or
increased levels of carbon monoxide in my referenced home.
1
2
S.28
S.29
S.30

I acknowledge having read, understood, and agreed to the above waiver, and release.
I decline the above waiver and release. (Skip to Q.108)

Participant Signature{Q48a.}
Name__________ {48b}
Date__________ {48c}
*This form generally indicates that the occupant or owner of the property agrees to waive his or her rights to sue
any individual, any municipality and any other organizations or individuals involved in the safety inspection of this
home, if a fire or increased levels of carbon monoxide occurs after the inspection. The purpose of the waiver is to
protect the individual or any of the organizations involved against liability arising from the home fire inspection.
This statement is intended for information only, the terms of the waiver themselves shall prevail if there are any
questions. You should seek advice if you do not understand this waiver.

(READ) “Thank you. Your input is very important to this research. My teammate will now gather the tools needed to
test your alarms. In the meantime, you and I will begin the questionnaire.
[INTERVIEWER] Alarm inspector should ensure all materials are available for alarm testing and call supervisor for
any needed supplies (ladder, measuring tape, etc.) If there are pets in the home, please politely ask the participant
if they can be placed in a separate room during the interview.
[MODULE 4: HOME CHARACTERISTICS]

[ASK ALL]
Q.1
Do you or another member of your household own or rent your home? (DO NOT READ LIST) {6}

1
2
98
99

Own
Rent
Don’t know
Refused

[ASK ALL]
Q.2
For how many years have you lived in this (apartment/house)? (DO NOT READ LIST) {7}

1
98
99

Drop down menu of full year integers [Include less than one year to 50 or more]
Don’t know
Refused

[ASK ALL]
Q.3
Please tell me to the best of your knowledge, in what year was this (apartment/house) built? Was it …
(READ LIST) {8}

1
2
3
4
5
6
7
98
99

2010 or later
Between 2000 and 2009
Between 1990 and 1999
Between 1980 and 1989
Between 1970 and 1979
Between 1960 and 1969
Before 1960
Don’t know (DON’T READ)
Refused (DON’T READ)

[IF “Single Family Detached Housing” or “Single Family Attached” (S.1=1-2), ASK:]
Q.4
What types of fuel-burning appliances, if any, do you own or have in your home? By fuel burning
appliances, we mean appliances that use gas, propane, oil, wood, wood pellets, coal, or kerosene. Do not
include electric-powered appliances. (READ LIST, SELECT ALL THAT APPLY) {9a}

1
2
3
4
5
6
7
8
9
98
99

Gas powered generator
Furnace or boiler
Water heater
Charcoal grill
Gas Dryer
Wood or pellet burning fireplace or stove
Kitchen appliances (e.g., stove, oven)
Other (Specify) [TEXTBOX]
Do not own any fuel-burning appliances [Exclusive]
Don’t know (DON’T READ) [Exclusive]
Refused (DON’T READ) [Exclusive]

[IF “Single Family Detached Housing” or “Single Family Attached” (S.1=1-2), ASK:]
Q.5
Does this residence have an attached garage unit? (DO NOT READ LIST) {9b}

1
2
98
99

Yes
No (SKIP TO Q.9)
Don’t know (SKIP TO Q.9)
Refused (SKIP TO Q.9)

[IF “Single Family Detached Housing” or “Single Family Attached” ( S.1=1-2), ASK:]
[IF “Yes” (Q5=1), ASK]
Q.6
For what purposes is the attached garage used? Would you say… (READ LIST, SELECT ALL THAT APPLY)
{9c}

1
2
3
4
5
98
99

Workshop/ workspace
Store tools or lawn/ sports equipment
Store vehicle(s) (e.g., motorcycle, car, SUV, van, etc.)
Fuel burning appliances (e.g., furnace, water heater, grill, etc.)
Other (Specify:) [TEXTBOX]
Don’t know
Refused

NO QUESTIONS Q.7-Q.8
[MODULE 5: SMOKE DETECTOR BEHAVIORS]
[ASK IF HAS SMOKE DETECTORS, S.15=1:].
Q.9
Please tell me to what extent do you believe your home is safe with your current smoke detectors? Would
you say ... {4d}
[READ LIST]

1
2
3
4
5
98
99

Not at all safe
Slightly safe
Moderately safe
Mostly Safe
Very safe
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK IF HAS SMOKE DETECTORS, S.15=1:]
Q.10a About how often do you use the test button to test the smoke detector or detectors in your home?
Would you say… (READ LIST) {10a}
1
2

Never
Once every few years (SKIP TO Q11a)

3
4
5
6
7
8
98
99

Once every year (SKIP TO Q11a)
Once every 6 months (SKIP TO Q11a)
Once every 3 months (SKIP TO Q11a)
Once every month (SKIP TO Q11a)
Once every week (SKIP TO Q11a)
Other (specify) [TEXTBOX] (SKIP TO Q11a)
Don’t know (DON’T READ) (SKIP TO Q11a)
Refused (DON’T READ) (SKIP TO Q11a)

[ASK IF HAS SMOKE DETECTORS & NEVER TESTS, S.15=1 & Q10a=1:]
Q.10b. Please tell me, what are some of the reasons that you have not tested your smoke detector or detectors?
(DO NOT READ LIST, SELECT ALL THAT APPLY):
1
2
3
4
5
6

Did not know you should test
Did not think it was important enough
Did not know how to test (SKIP TO 11a)
Don’t need to test because they go off occasionally
Physically unable to reach
Other (Specify) [Textbox]

99

Refused

98

Don’t know

[ASK IF HAS SMOKE DETECTORS & NEVER TESTS, S.15=1 & Q10a=1:]
Q.10c. Do you know how to test your smoke detector or detectors, or not? (DO NOT READ LIST)
1
2
98
99

Yes
No
Unsure
Refused

[ASK IF HAS SMOKE DETECTORS, S.15=1:]
Q.11a Do you think most, or all of your smoke detectors are working? By working, I mean they would make a
sound if they detected smoke right now. (DO NOT READ LIST)
1
2
98
99

Yes (SKIP to Q12)
No
Don’t know (SKIP TO Q12)
Refused (SKIP TO Q12)

[ASK IF 11a=2, “No”:]
Q.11b What are some of the reasons your smoke detectors may not be working? Again, by working, I mean they
would make a sound if it detected smoke right now. (DO NOT READ LIST, SELECT ALL THAT APPLY)
1
2
3
4
5
6
7

Did not get around to fixing it
Do not know how to fix or replace it
Unable to install or fix it
Unable to afford new ones
Disconnected it (GO TO Q.11c)
It is the landlord’s responsibility
Removed battery (GO TO Q.11d)

8
9
10
98
99

Batteries never installed
Batteries not working and not yet replaced
Other reason [TEXTBOX]
Don’t know
Refused

[ASK IF 11b=5, “Disconnected it”]
Q.11c You mentioned that one or more of your smoke detectors was disconnected. For what reason(s) were the
smoke detectors disconnected? (DO NOT READ LIST, SELECT ALL THAT APPLY)
1
2
3
4
5
6
98
99

Nuisance when they go off
Detector frequently went off
Would not stop beeping/ chirping
No longer worked
No reason in particular
Other reason [TEXTBOX]
Don’t know
Refused

[ASK IF 11b=7, “Removed battery”]
Q.11d You mentioned that the batteries were removed from one or more of your smoke detectors. For what
reason(s) were the batteries removed from the smoke detector or detectors? (DO NOT READ LIST, SELECT
ALL THAT APPLY)
1
2
3
4
5
6
7
8
98
99

Batteries no longer worked
Batteries were leaking/ discharge
Batteries expired
Detector would not stop beeping/chirping
Intended to replace batteries, but forgot to install new ones
Installed wrong type of batteries
Needed batteries for another device
Other reason ________________________
Don’t know
Refused

[ASK IF HAS SMOKE DETECTORS, S.15=1:].
Q.12
Do you know how to… (DO NOT READ RESPONSE OPTIONS)

a.
b.

Install a smoke detector?
Maintain a smoke detector in good working order?

[Response Options]
1
Yes
2
No
98
Unsure
99
Refused
[ASK IF HAS SMOKE DETECTORS, S.15=1:].
Q.13
To the best of your knowledge, how often should you replace your old smoke detector with a new smoke
detector in your home? Would you say… (READ LIST)

1
2
3
4
5
6
7

98
99

Never, unless the detector stops working
Once every 6 months
Once a year
Once every 2 – 5 years
Once every 6 – 9 years
Once every 10 years
Once every 10+ years

Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:].
Q. 14 On a scale of 1 to 5, where 1 is “Not at All Necessary”, and 5 is “Extremely Necessary”, how necessary do
you feel it is to have a smoke detector installed in your home? {Q29}

1
2
3
4
5
98
99

1 – Not at All Necessary
2
3
4
5 – Extremely Necessary
Don’t Know
Refused

[ASK IF NO SMOKE DETECTOR, S.15=2]
Q.15
Please tell me what are some of the reasons you don’t have a smoke detector installed in your home? (DO
NOT READ LIST, SELECT ALL THAT APPLY) {Q30}

1
2
3
4
5
6
7
98
99

Don’t think I need one
Did not come with residence
They are a nuisance
They did not or don’t work
Never got around to replacing previous detectors
It is the landlord’s responsibility
Other reason[Textbox]
Don’t know
Refused

[MODULE 6: FIRE HISTORY]
[ASK ALL:]
Q.16
In the past 12 months, have you had any accidental fires – that is unintended or unwanted smoke or
flames - in your home? Please include fires that were too small to call the fire department. (DO NOT READ
LIST) {14a}

1
2
98
99

Yes (CONTINUE)
No (SKIP TO Q.17)
Don’t know (SKIP TO Q.17)
Refused (SKIP TO Q.17)

[ASK IF “Yes”, Q16=1:]
Q.16a Thinking of the most recent accidental fire(s), how did you become alerted to the incident? (DO NOT
READ LIST, SELECT ALL THAT APPLY) {14b}

1
2
3
4
5
6
7
8
98
99

Saw the fire
Smelled the fire
Heard the fire
Felt the heat of the fire
Smoke detector (SKIP Q16c)
Someone notified me
Other (Specify) [textbox]
Don’t remember
Don’t know
Refused

IF S.15=1, “Has smoke alarms”, CONTINUE
ELSE SKIP TO Q.20
[ASK IF Q16 “Has smoke alarms” AND “Yes” had accidental fires, Q16=1 AND S.15=1]
[ASK IF Q16a OTHER THAN “Smoke detector” Q16a= 1-4, 6-8,98-99]
Q.16b Thinking of the most recent accidental fire(s), did any of the smoke detectors go off during the fire(s)? (DO
NOT READ LIST) {14c}

1
2
98
99

Yes (SKIP TO Q.17)
No
Don’t know (SKIP TO Q.17)
Refused (SKIP TO Q.17)

[ASK IF Q16b= “No”, Q16b=2]
Q.16c Thinking of the most recent accidental fire(s), do you think that enough smoke reached the smoke
detector that it should have sounded? (DO NOT READ LIST) {14d}

1
2
98
99

Yes
No
Don’t know
Refused

[ASK IF HAS SMOKE ALARMS, S.15=1]
Q.17
In the past 12 months, have any of your smoke detectors gone off when there was no fire, other than
when the smoke detector was being tested? (DO NOT READ LIST) {Q15a}

1
2
98
99

Yes
No
Don’t know
Refused

[ASK IF Q17=1, “Yes”]
Q.17a Why do you think the smoke detector went off when there was no fire? (DO NOT READ LIST, SELECT ALL
THAT APPLY).{15b}

1
2
3
4
5
6
7
98
99

Cooking
Fireplace
Tobacco
Steam from bathroom
Low battery
Other (Specify:) [textbox]
No apparent reason
Don’t know
Refused

NO QUESTIONS 18-19
[MODULE 7: CO DETECTORS]
[ASK IF HAS CO DETECTORS, S.19=1:].
Q.20
Please tell me to what extent do you believe your home is safe with your current carbon monoxide
detectors? Would you say... (READ LIST) {5d}
[READ LIST]

1
2
3
4
5
98
99

Not at all safe
Slightly safe
Moderately safe
Mostly Safe
Very safe
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.21
How would you know if high levels of carbon monoxide (CO) were present in your home? (DO NOT READ
LIST, SELECT ALL THAT APPLY). {16}

1

You can smell it

2
3
4
5
6
7
98
99

You can taste it
You can see it
You can feel it
Carbon monoxide detector
Other (Specify:) [textbox]
Respondent does not believe there is a way to know if CO is present
Don’t know
Refused

[ASK ALL:]
Q.22
How much do you believe you know about carbon monoxide detectors? (READ LIST) {17}

1
2
3
4
98
99

Nothing at all
A little
Some
A lot
Don’t know (DON’T READ)
Refused (DON’T READ)

IF HAS CO DETECTORS, S.19=1 CONTINUE
ELSE SKIP TO Q.27
[ASK IF HAS CO DETECTORS, S.19=1:].
Q.23
About how often do you use the test button to test your carbon monoxide detector or detectors? Would
you say… (READ LIST) {18a}
[READ LIST]

1
2
3
4
5
6
7
8
9
10

Never
Once every few years (SKIP TO Q24)
Once every year (SKIP TO Q24)
Once every 6 months (SKIP TO Q24)
Once every 3 months (SKIP TO Q24)
Once every month (SKIP TO Q24)
Once every week (SKIP TO Q24)
Other (specify) [TEXTBOX] (SKIP TO Q24)
Don’t know (SKIP TO Q24) (DON’T READ)
Refused (SKIP TO Q24) (DON’T READ)

[ASK IF HAS CO DETECTORS, S.19=1:]
[ASK IF NEVER TESTS, Q.23=1:].
Q.23a What were the reasons that you have not tested your carbon monoxide detector or detectors? (Open
ended, capture their response) {18b}

1

[Text box]

[ASK IF HAS CO DETECTORS, S.19=1:]

Q.24

Do you think most or all of your carbon monoxide detectors are working? By working, I mean they would
make a sound if they detected carbon monoxide right now. (DO NOT READ LIST) {19a}
1
2
98
99

Yes (SKIP TO Q.25)
No
Don’t know (SKIP TO Q.25)
Refused (SKIP TO Q.25)

[ASK IF 24=2, “No”:]
Q.24a What are some of the reasons your carbon monoxide detectors may not be working? Again, by working, I
mean they would make a sound if it detected carbon monoxide right now. (DO NOT READ LIST, SELECT
ALL THAT APPLY) {19b}
1
2
3
4
5
6
7
8
9
10
98
99

Did not get around to fixing it
Do not know how to fix or replace it
Unable to install or fix it
Unable to afford new ones
Disconnected it
It is the landlord’s responsibility
Removed battery
Batteries never installed
Batteries not working and not yet replaced
Other reason [textbox]
Don’t know
Refused

[ASK IF 24a= “Disconnected it”, 24a=5,]
Q.24b You mentioned that one or more of your carbon monoxide detectors was disconnected. For what
reason(s) were the carbon monoxide detectors disconnected? (DO NOT READ LIST, SELECT ALL THAT
APPLY) {19c}
1
2
3
4
5
6
98
99

Nuisance when they go off
Detector frequently went off
Would not stop beeping/ chirping
No longer worked
No reason in particular
Other reason [textbox]
Don’t know
Refused

[ASK IF Q24a= “Removed battery”, Q24a=7]
Q.24c You mentioned that the batteries were removed from one or more of your carbon monoxide detectors.
For what reason(s) were the batteries removed from the smoke detector or detectors? (DO NOT READ
LIST, SELECT ALL THAT APPLY) {19d}
1
2
3
4
5
6
7

Batteries no longer worked
Batteries were leaking/ discharge
Batteries expired
Detector would not stop beeping/chirping
Intended to replace batteries, but forgot to install new ones
Installed wrong type of batteries
Needed batteries for another device

8
98
99

Other reason [textbox]
Don’t know
Refused

[ASK IF HAS CO DETECTORS, S.19=1:]
Q.25
For what reasons do you have a carbon monoxide detector? (DO NOT READ LIST, SELECT ALL THAT APPLY)
{Q20}

1
2
3
4
5
6
98
99

It is required by law
It makes me feel safe
It is helpful in detecting carbon monoxide
It came with the residence
I own generators/ fuel-burning appliances
Other (Specify:) [textbox]
Don’t know
Refused

[ASK IF HAS CO DETECTORS, S.19=1:].
Q.26
To the best of your knowledge, how often should the carbon monoxide detectors in your home be
replaced? Would you say… (READ LIST)
1
2
3
4
5
6
7
98.
99.

Never, unless the detector stops working
Once every 6 months
Once a year
Once every 2 – 5 years
Once every 6 – 9 years
Once every 10 years
Once every 10+ years
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:].
Q. 27 On a scale of 1 to 5, where 1 is “Not at All Necessary”, and 5 is “Extremely Necessary”, how necessary do
you feel it is to have a carbon monoxide detector installed in your home? {Q31}

1
2
3
4
5
98
99

1 – Not at all necessary
2
3
4
5 – Extremely Necessary
Don’t Know
Refused

[ASK IF NO CO DETECTOR, S.19=2]
Q.28
Please tell me what are some of the reasons you don’t have a carbon monoxide detector installed in your
home. (PRECODED LIST. DO NOT READ, SELECT ALL THAT APPLY) {Q32}

1
2

Don’t think I need one
Did not come with residence

3
4
5
6
7
98
99

They are a nuisance
They did not or don’t work
Never got around to replacing previous detectors
It is the landlord’s responsibility
Other reason [Textbox]
Don’t know
Refused

NO QUESTION 29
IF NO CO DETECTORS, S.19 = 2, SKIP TO Q32
ELSE, CONTINUE
[MODULE 8: CO History]
[ASK IF HAS CO DETECTORS, S.19=1:]
Q.30
In the past 12 months, has your carbon monoxide detector or detectors ever gone off, other than when
the carbon monoxide detector was being tested? (DO NOT READ LIST) {22a}

1
2
98
99

Yes
No (SKIP TO Q31)
Don’t know (SKIP TO Q31)
Refused (SKIP TO Q31)

[ASK IF Q30= “Yes”, Q30=1:]
Q.30a Thinking of the last time your carbon monoxide detector went off, how did you react when you heard the
detector? (DO NOT READ LIST, SELECT ALL THAT APPLY) {22b}

1
2
3
4
5
6
7
8
98
99

Left the house
Called the fire department
Ventilated home (opened windows, door, used fan, etc.)
Unplugged or disconnected it
Reset it
Removed battery
Other action (specify) [textbox]
Don’t remember
Don’t know
Refused

[ASK IF HAS CO DETECTORS, S.19=1:].
Q.31
Do you know how to…(DO NOT READ RESPONSE OPTIONS) {23}

a.
b.

Install a carbon monoxide detector?
Maintain a carbon monoxide detector in good working order?

[Response Options]
1
Yes

2
98
99

No
Unsure
Refused

[ASK ALL:]
Q.32
In the past 12 months, were you aware that any of your friends, relatives, neighbors, or coworkers
experienced…(DO NOT READ RESPONSE OPTIONS) {Q24}

a.
b.

An accidental fire?
A carbon monoxide incident? (e.g., effects of carbon monoxide poisoning)

[Response Option]
1
Yes
2
No
98
Unsure
99
Refused
[MODULE 9: Fire Safety Sources]
[ASK ALL:]
Q.33
In the past 12 months, have you looked for any information about either fire safety or carbon monoxide
safety, or not? (DO NOT READ LIST) {34a}

1
2
98
99

Yes
No (SKIP TO Q36)
Unsure (SKIP TO Q36)
Refused (SKIP TO Q36)

[ASK IF Q.33=1:]
Q.34
Where do you obtain information about fire safety? (READ LIST ONE AT A TIME) (SELECT ALL THAT
APPLY) {34b}

1
2
3
4
5
6
7
8
98
99

TV news, or radio
Internet search engines like Google
Family or friends
Community or religious organizations
Social media like Facebook
Local fire department
Other (SPECIFY) (DON’T READ) [Textbox]
None of these (DON’T READ)
Don’t know or remember (DON’T READ)
Refused (DON’T READ)

[ASK IF Q.33=1:]
Q.35
Where do you obtain information about carbon monoxide safety? (READ LIST ONE AT A TIME) (SELECT
ALL THAT APPLY) {34c}

1
2
3
4
5
6
7
8
98
99

TV news, or radio
Internet search engines like Google
Family or friends
Community or religious organizations
Social media like Facebook
Local fire department
Other (SPECIFY) (DON’T READ) [Textbox]
None of these (DON’T READ)
Don’t know or remember (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.36
How often do you or another member of the household cook at home using a stove or oven? Does a
member of this household cook… (READ LIST)? {35}

1.
2.
3.
4.
5.
98.
99.

Never
A few times per year
A few times per month
A few times per week
Every day
Don’t know (DON’T READ)
Refused (DON’T READ)

[OBSERVE:]
Q.37
Time: ___ (hh:mm AM/PM)
NO QUESTIONS 38-39
[MODULE 10a: Alarm Testing]
[Interviewer note: Reintroduce team member who will conduct alarm test and hand them the tablet to continue
the interview.]
“Now we’d like to test your detector(s) to make sure that they are working properly.”
[ASK ALL:]
Q.40
(READ) How many floors (levels) are there in your home? Please include the basement and finished attic,
if you have one. {25}
[INTERVIEWER] For an apartment, treat the entire apartment as one floor unless more than one level. DO
NOT report the number of floors in the apartment building.
[Dropdown]

1.
2.
3.
4.

1
2
3
4

5.
6.

5
6 or more

[Interviewer note: Q41 through Q79 asked/conducted for each smoke alarm and each CO alarm]
[ASK ALL:]
Q.41
(READ) Would you show me the (first/next) detector? {25B}
[INTERVIEWER] Please ensure to have all materials are available and prepared for testing. If there are no
more alarms to test, select “No more alarms available for testing” to skip the alarm testing portion.

1.
2.

Begin inspection
No more alarms available for testing (SKIP TO Q80)

[ASK IF Q.41=1:]
Q.42
(READ) What level of the home are we currently on? (NOTE: For an apartment, treat the entire apartment
as first level unless more than one level. Do NOT report what floor of the building it is on.) {26a}

1
2
3
4
5
6
7
8
9

Basement
First level
Second level
Third level
Fourth level
Fifth level
Sixth level
Finished attic
Other [Textbox]

[ASK IF Q.41=1:]
Q.43
(OBSERVE) What area or room of the home are you currently in? {26b}

1
2
3
4
5
6
7
8
9
10
11

Inside the bedroom
Hallway outside of bedrooms
Hallway - other
In Family room/Living room
In Kitchen
In Dining area
In Bathroom
In Closet
In Stairwell
In Laundry room /Storage room
Other area

[ASK IF Q.41=1:]
Q.44
(READ) What type of detector is this? Would you say it is a smoke detector, carbon monoxide detector,
both a smoke and CO detector, or you don’t know? {26C}

1
2
3
4

Smoke detector
CO detector
Smoke/CO Combined
Don’t know or other (INSPECT)

[ASK IF Q.44=4]
Q.44a [INTERVIEWER] Please inspect back of detector for manufacturer information - look for name/ type of
detector. Please select correct type of detector. {26C2}

1
2
3

Smoke detector
CO detector
Smoke/CO Combined

NO QUESTION Q.45
[ASK IF Q.41=1:]
Q.46
(READ) For quality control purposes, we’d like to collect three photographs of this detector. Do we have
your permission? {26d}

1
2
3

Yes
No
Could not take picture

[ASK IF “No”, Q.46=2]
“Okay. No problem.”
[ASK IF Q.46=1]
Q.46a [INTERVIEWER] Only remove the alarm from the mounting plate to see the back of the alarm,
disconnected only the ac pig tail if needed. Do not cut or disconnect any electrical wires connected to the
wall or ceiling directly.
Please obtain three photographs including the following items.
Instructions:

1)
2)
3)
4)

Press the "Upload" button.
Select the camera option.
Take picture.
Accept picture.

[ASK IF Q.46=1]
Q.46a [IMAGE UPLOAD] Front of detector (to capture image of detector)
Q.46b [IMAGE UPLOAD] Back of detector (UL and Manufacturer information)
Q.46c [IMAGE UPLOAD] Side of detector (may have a install/replacement sticker)
[ASK Q.41=1, Alarm Testing Being Conducted]
Q.47
(READ) How old do you think this detector is? Would you say… {26w}

1

Less than 1 year old

2
3
4
5
6

1 – 5 years old
6 – 10 years old
More than 10 years old
Don’t know (DON’T READ)
Refused (DON’T READ)

IF Q.44 or Q44a= “Smoke Alarm” or “Smoke/CO Combined” Continue
ELSE IF Q.44 or Q44a= “CO”, SKIP TO CO TESTING Q.52
[MODULE 10b: Smoke Alarm Testing]
[ASK IF Q.44 or Q44a= “Smoke Alarm” or “Smoke/CO Combined:]
Q.48a (READ) Is there a kitchen with a stove top on this floor? {26e1}

1
2

Yes
No (SKIP TO Q.49)

[ASK IF Q.48a=1:]
Q.48b (READ) Is this alarm the closest to the Kitchen with a stove top? {26e2}

1
2

Yes
No (SKIP TO Q.49)

[ASK IF Q.48b=1:]
Q.48c (OBSERVE) Approximately, what is the horizontal distance between the stove or cooktop in the kitchen
and the closest smoke detector on the same floor? Use measuring tape if necessary. {26e3}

1
2
3
4
98

Less than 6 feet
6 – 10 feet
11 – 20 feet
More than 20 feet
Don’t know

[ASK IF Q.44 or Q44a= “Smoke Alarm” or “Smoke/CO Combined:]
Q.49
INSTRUCTIONS ON TESTING SMOKE DETECTOR WITH AEROSOL-SMOKE TEST

•
•
•

Warn consumer of loud noise when the smoke detector sounds.
Use hearing protection, if needed.
Only disconnect alarms from AC Pig tails. Do not disconnect AC pig tails from
other electrical wires in the wall/ceiling.

FIRST SMOKE TEST:

1)
2)
3)

Using the aerosol smoke test spray, point tube at detector from a distance of 1 –
2 feet
Spray a three second burst of aerosol, and wait 10 seconds
If detector sounds, testing is complete.

4)

Spray short burst of canned air to accelerate and clear smoke detector

IF NO DETECTOR SOUNDS:

1)
2)
3)
4)

Using microfiber cloth, brush alarm lightly clear grille and surface of detector
Spray again using aerosol smoke test for 5 seconds and wait 10 seconds
If detector sounds, testing is complete
Spray short burst of canned air to accelerate and clear smoke detector

(OBSERVE) Did smoke detector sound in response to this smoke test? {26f}

1
2
3

Yes (SKIP TO Q.51 IF COMBINED ALARM, OR Q.58 IF SMOKE ONLY)
No (CONTINUE)
Could not test (SKIP TO Q.75)

[ASK IF Q.49=2, SMOKE DETECTOR DID NOT SOUND:]
Q.50
INSTRUCTIONS ON TESTING USING TEST(S) BUTTON

•
•
1)
2)
3)

Warn consumer of loud noise when the smoke detector sounds.
Use hearing protection, if needed.
Read directions on detector for testing function (push and release/push and
hold)
Press and hold the “Test” button according to directions
If detector sounds, testing is complete. Label for collection due to inoperable
sensor

(OBSERVE) Did detector sound in response to the smoke test button? {26g1}

1
2
3
4

Yes (SKIP TO Q.58 – INOPEREABLE)
No (SKIP TO Q.53 – BATTERY REPLACEMENT)
No test button on unit (SKIP TO Q.53 – BATTERY REPLACEMENT)
Could not test (SKIP TO Q.75)

[MODULE 10c: Combination CO/Smoke Alarm Testing]
[ASK IF COMBINATION CO/SMOKE ALARM, Q.44 or Q44a=3]
Q.51
INSTRUCTIONS ON TESTING COMBINED CO DETECTORS

1)
2)
3)

Press and hold the “Test/Reset” button until the detector sounds
Release the “Test/Reset” button
If detector sounds, testing is complete

(OBSERVE) Did detector sound in response to the second (CO) test button? {26g2}

1
2

Yes (SKIP TO Q.58)
No (SKIP TO Q.58 – INOPERABLE)

3

No test button on unit (SKIP TO Q.58)

[MODULE 10d: CO Alarm Testing Only]
[ASK IF CO ALARM, Q.44 or Q44a=2:]
Q.52
INSTRUCTIONS ON TESTING CO DETECTOR ONLY

•
•
•
1)
2)
3)

Warn consumer of loud noise when the CO detector sounds.
Use hearing protection, if needed.
Only disconnect alarms from AC Pig tails. Do not disconnect AC pig tails from
other electrical wires in the wall/ceiling.
Press and hold the “Test/ Reset” until the detector sounds
Place your fingers over the sounder opening and check the power and detector
by releasing the “Test/Reset” button.
If detector sounds, testing is complete.

(OBSERVE) Did detector sound in response to the CO test button? {26g3}

1
2
3

Yes (SKIP TO Q.60)
No (CONTINUE TO BATTERY, Q.53)
Could not test (SKIP TO Q.75)

[MODULE 11: Battery Replacement & Retesting]
[ASK IF SMOKE DETECTOR DID NOT SOUND TO SMOKE TEST BUTTON, OR NO TEST BUTTON ON UNIT, Q.50=2 or 3:]
[ASK IF Q.52=2, CO DETECTOR ONLY DID NOT SOUND DURING TEST:]
Q.53
REPLACING/INSTALLING BATTERY
[INTERVIEWER] You will now attempt to change the batteries on the non-working alarm.

1)
2)

Verify the type of batteries the alarm may need and check your inventory.
If the smoke detector uses a 10-year seal battery, the battery cannot be
replaced. A smoke detector that uses a 10-year sealed battery can be identified
if:
a. The unit does not have a battery door or compartment.
b. The label states “10-year seal battery” or similar.

(READ) May I put a new battery in this detector to determine whether the detector needs to be
replaced? {26h}

1
2

Yes (CONTINUE)
No (Label for collection) (SKIP TO Q.58 IF SMOKE/COMBINATION OR Q.60 IF CO
ONLY)

3
4

No – 10-year Seal Battery Present or AC only (Label for collection) (SKIP TO Q.58
IF SMOKE/COMBINATION OR Q.60 IF CO ONLY)
No replacement batteries available (SKIP TO Q.75)

[ASK IF Q.53=1, “Yes” TO CHANGING BATTERY AND Q44/Q44a=1” SMOKE” OR “3” COMBINATION]
Q.54
REPLACING/INSTALLING BATTERY

1)
2)

Replace or restore batteries in detector
Repeat smoke test using up to 3- one second sprays, ten seconds apart with tube
against the grill.

(OBSERVE) Did the detector sound in response to this smoke test? {26i}

1
2

Yes (SKIP TO Q.58)
No (Label for collection-INOPERABLE) (SKIP TO Q.58)

NO QUESTION Q.55
[ASK IF Q.53=1 AND Q44/Q44a= 2 “CO” OR 3 “COMBINATION”]
Q.56
INSTRUCTIONS ON RETESTING CO DETECTOR TEST BUTTON

1)
2)

Press and hold the “Test/ Reset” until the detector sounds
If detector sounds, testing is complete.

(OBSERVE) Did detector sound in response to the second test button? {26j2}

1
2

Yes (CONTINUE)
No (Label for collection) (CONTINUE)

NO QUESTION Q.57
IF Q44/Q44a=1” SMOKE” OR 3 “COMBINATION” CONTINUE
ELSE SKIP TO Q59
[MODULE 12: DETECTOR CHARACTERISTICS]
[ASK IF Q44/Q44a=1” SMOKE” OR 3 “COMBINATION”]
Q.58
(OBSERVE) What type of smoke detector is this? {26L}

1
2
3
4
5
98
99

Photoelectric
Ionization
Combined photo/ion
Combined ion with CO
Combined photo with CO
Don’t know
Other ________

NO QUESTION 59
[ASK IF Q.41=1:]
Q.60 (OBSERVE) What type of power source does the detector have? {26n}

1
2
3
4
98

Replaceable battery
Sealed battery
AC Only
AC with battery
Don’t know

[ASK IF Q.41=1:]
Q.61 (OBSERVE) What is the manufacture date of the detector? {26o}

1
98

Year [textbox]
Don’t know

[ASK IF Q.41=1:]
Q.62
(OBSERVE) What is the model number of the detector? {26p}

1
98

Model number [textbox]
Don’t know

[ASK IF Q.41=1:]
Q.63 (OBSERVE) Is the detector interconnected with other detectors in the home, (i.e., a wired detector), OR is
it a standalone wire free detector (i.e., a wireless detector)? {26q}

1
2
98

Yes
No
Don’t know

NO QUESTION 64
[ASK IF Q.41=1:]
Q.65 (OBSERVE) Does the detector have strobe lighting for hearing impaired? {26s}

1
2
98

Yes
No
Don’t know

[ASK IF Q.41=1:]
Q.66 (OBSERVE) Is this detector connected to a tactile notification device (bed shaker or pillow shaker) for the
hearing impaired or blind? {26t}

1

Yes

2
98

No
Don’t know

[MODULE 13: BATTERY RELATED]
[ASK IF Q60=1, “Replaceable battery”]
Q.68
(OBSERVE) Was this detector found to have a dead battery, (e.g., the old battery was connected but the
detector responded to aerosol smoke after battery replacement?) {26u}

1
2

Yes
No

[ASK IF Q.60=1-4, “Battery” or “AC”]
Q.69
(OBSERVE) Was the detector found without a battery, with battery disconnected, or AC power
disconnected? {26v}

1
2

Yes
No

[MODULE 14: NON-WORKING DETECTORS]
[ASK IF DETECTOR DOES NOT WORK: SEE APRENDIX II FOR COMBINATIONS]
Q.70
(READ) “It is important that we determine why detectors don’t work. “
“I would like to collect this detector and send it to the U.S. Consumer Product Safety Commissions lab for
analysis to find out why it does not work properly.”
(READ) May I collect this detector? {26x}

1
2

Yes
No

[ASK IF DETECTOR DOES NOT WORK: SEE APRENDIX II FOR COMBINATIONS]
Q.71
(READ) “I will need to label this alarm as inoperable/not working. Please do not remove the label. “
Directions: Place a label from the provided label sheet on the front of the detector (not covering any
important information) and record the identification number below. {26x}

1

Label number [textbox]

[SHOWN IF Q70=2]
Q.72
[Interviewer] Take and image of the shipping label/ tracking sticker and upload before handing to
participant.
(READ) “That is fine. You may keep the detector today. However, I will still provide you with a new
detector, and give you this mailer so you may send your old detector to the U.S. Consumer Product Safety
Commission’s lab for analysis, if you choose to do so? {26xb}
1

[UPLOAD IMAGE]

NO QUESTION 73
Q.74

[INTERVIEWER]

1)
2)

We are only able to provide up to 3 alarms per household.
Read script based on availability.

If alarms available: "We are able to provide a replacement smoke smoke/CO detector based on
availability."
If alarms not available: “Unfortunately, we do not have any additional alarms to provide based on
availability.” (Select option 3 and do not read question text below.)
(READ) Would you like a replacement to this alarm? {26xb2}

1
2
3

Yes
No, I do not want a replacement alarm (SKIP TO Q.75)
No replacement alarms available (SKIP TO Q.75)

[SHOW IF Q70=1]
[INTERVIEWER] Carefully Package detector according to checklist.
[SHOW IF Q74=1]
(AFTER DETECTOR HAS BEEN REMOVED/BOX GIVEN):
(READ)” Here is a replacement (smoke/CO) detector. I’m going to test it now to be sure it works. If you need any
assistance installing the detector, please reach out to your local fire department”

1)
2)
3)

Perform Button Test
If detector sounded, Install or give respondent replacement detector.
If detector does not sound, select & test another detector

[MODULE 15: Reporting on Testing]
[ASK IF Q.41=1, Alarm Testing Being Conducted]
Q.75
(OBSERVE) Post inspection actions taken: (SELECT ALL THAT APPLY) {26y}

1
2
3
4
5
6
7
8
9

No action required
Battery replaced
Installed missing battery
Refused battery installation/ replacement
No batteries available for replacement
Collected detector
Advised replacement (AC/ hard wired)
Could not provide replacement detector/ Refused
Could not test detector

[ASK Q.75=9, “Could not test detector”]
Q.75a If could not test, why not? {26k}

1
2
3
4

Could not reach
Homeowner would not allow
No time
Other [Textbox]

[ASK IF Q.41=1, Alarm Testing Being Conducted]
Q.76
(READ) Are there any other detectors on this floor? This could include smoke detectors or carbon
monoxide detectors. {26z}

1
2
3

Yes
No
Don’t know

[ASK IF Q.41=1, Alarm Testing Being Conducted]
Q.77
(READ) What about other floors? Are there any smoke or carbon monoxide detectors on any other floors
in this (house/apartment)? {26aa}

1
2
3

Yes
No
Don’t know

Q.78
[OBSERVE] Time: ___ (hh:mm AM/PM)
NO QUESTION 79
Q.80
[INTERVIEWER] Check the time count for possibility to test additional alarms. If more than 30 minutes out
of 60 minutes remain, ask participant to guide you to the next alarm. If there are fewer than 30 minutes
remaining, do not test additional alarms. Select No, all alarms have been inspected (Q80=2).
If time allows, visually verify that there is another alarm to test before making a selection.
Once you select "Yes" the questions on Alarm inspection/testing will repeat for the next alarm.
Select "No, all alarms have been tested" If you have verified all smoke and CO alarms have been tested,
OR if there is not enough time within the 60 minutes allotted. The system will move on to the next section
and you will not be able to collect any additional alarm testing data.
Is there another alarm to test? {26ab}

1
2

Yes
No, all alarms have been inspected

[Interviewer note/reminder: If respondent asks why you are not testing any additional alarms, explain
that to continue testing and complete the remainder of the survey questions will take longer than the
allotted 60 minutes. The government approved survey only allows you to be in their home for 60 minutes.
END OF ALARM TESTING LOOP

THE LOOP WILL REPEAT FROM Q.41 IF Q.80=1
ELSE, CONTINUE
[MODULE 16: DETECTORS]
NO QUESTION 81
[ASK Q.44 OR Q.44a= 1 or 3]
Q.82
Interviewer: Thinking about the smoke alarms that you just tested, did the participant know the location
of the smoke detectors in their home? {27a}

1
2
3

Yes, Knew all of them
Yes, Knew at least one, but not all
No, knew none of the locations

NO QUESTION 83
[ASK Q.44 OR Q.44a= 2]
Q.84
Interviewer: Thinking about the carbon monoxide alarms that you just tested, did the participant know
the location of the carbon monoxide detectors? {28a}

1
2
3

Yes, Knew all of them
Yes, Knew at least one, but not all
No, knew none of the locations

Great! To ensure that we interview a broad mix of residents, I have a few brief demographic questions to ask about
you and others within the household. It should only take a few minutes of your time.
[ASK ALL:]
Q.85
How many people live or stay in your household? This can include:

o Anyone who is living or staying here for more than 2 months
o Yourself, if you are living here for more than 2 months
o Anyone else staying here who does not have another place to stay, even if they
are here for 2 months or less
Please do not include anyone who is living somewhere else for more than 2 months, such as a college student
living away or someone in the Armed Forces on deployment. {Q36}

1

Enter number of people

[ASK ALL:]
Q.86
Thinking of the individual(s) who live here, including yourself, is there anyone… (INSERT ITEM) {37}

a

Under 5 years old

b
c
d
e
f
g
h

5 to 9 years old
10 to 14 years old
15 to 19 years old
20 to 34 years old
35 to 54 years old
55 to 64 years old
65 years old or older

RESPONSE OPTIONS

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

NO QUESTIONS 87-90
[ASK ALL:]
Q.91
Thinking of the individual(s) who live here, including yourself, how many are … (INSERT ITEM) {37a}
[Carry forward any Q90=1]

a
b
c
d
e
f
g
h

Under 5 years old
5-9 years old
10-14 years old
15-19 years old
20 to 34 years old
35 to 54 years old
55 to 64 years old
65 years old or older

RESPONSE OPTIONS

1

Enter number of people

[ASK ALL:]
Q.92
What is the highest level of education you have completed or the highest degree you have received? (DO
NOT READ LIST) {Q38}

1
2
3
4
5
6
7

Less than high school, no diploma
High school diploma, or high school equivalent (GED)
Trade or Vocational school degree
Some college, no degree
Associate’s degree
Bachelor’s degree
Master’s degree or higher

98
99

Don’t know
Refused

[ASK ALL:]
Q.93
Are you of Hispanic, Latino, or Spanish origin, such as Mexican, Puerto Rican or Cuban? (DO NOT READ
LIST)

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.94
What is your race? (SELECT ALL THAT APPLY) {Q40}

1
2
3
4
5
6
7

98
99

White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Some Other Race (Specify) [TEXTBOX]
Hispanic/Latino (e.g., Mexican, Puerto Rican, Cuban)

Don’t know (DON’T READ)
Refused (DON’T READ)

[IF NOT HISPANIC (Q93=2-99), ASK:]
Q.95
Is anyone in the household of Hispanic or Latino origin or descent? (DO NOT READ LIST) {Q39}

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.96
Is anyone in the household deaf or hard of hearing? (DO NOT READ LIST) {Q.41}

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.97
Does anyone in the household have a physical, mental, or other health condition that has lasted 6 or more
months which makes it difficult for them to carry out day to day activities? (DO NOT READ LIST) {Q.42}

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.98
Do any people in the home smoke cigarettes, cigars, hookahs, or pipes? Please do not include e-cigarettes
or vaping devices. (DO NOT READ LIST) {Q.43}

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.99
In the last 12 months, what was your total household income from all sources, before taxes? Just stop me
when I get to the right category (READ LIST) (If necessary, read) {Q.44}

1
2
3
4
5
6
7
8
9
98
99

Less than $15,000
$15,000 to under $25,000
$25,000 to under $35,000
$35,000 to under $50,000
$50,000 to under $75,000
$75,000 to under $100,000
$100,000 to under $150,000
$150,000 to under $200,000
$200,000 or more
Don’t know (DON’T READ)
Refused (DON’T READ)

Q.100 [OBSERVE:] Time visit ended: ___ (hh:mm AM/PM)
NO QUESTIONS 101-103
[MODULE 18: INCENTIVE]
[ASK ALL:]
Q.104 Incentive Form
[INTERVIEWER:] Important Note. Do not hand participant gift card until you have verified their
information.
(READ) “Thank you so much for participating in this survey. Your answers will help with improving
household fire and CO safety across the U.S. As a token of our appreciation for completing the survey, we
would like to provide you with this $50 gift card. Here is a short informational card about how best to use
the gift card."
(READ) “Please verify that the following information is correct”

[INTERVIEWER: Show participant the next page and once all information is confirmed provide incentive
card. Have participant sign receipt of card.
[PIPPED IN FIRST & LAST NAME FROM CONSENT]
[PIPPED IN STREET ADDRESS]
[PIPPED IN APT/SUITE #]
[PIPPED IN CITY], [PIPPED IN STATE] [PIPPED IN ZIP CODE]
I acknowledge that all this information is correct and that my $50 gift card for completing the In-home
Smoke and CO Study has been provided. {Q.46}
Q104a Signature
[ASK ALL:]
Q.105 At a later date, the research team may want to talk further with people who took part in this survey.
Would you be willing to talk to them about the survey at a convenient time in the future?

1
2
98
99

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK IF Q.105=1:]
Q.106 So that someone can reach you more easily, I just need to confirm your name, best phone number and
email address.

1
2
3

Name:
Best phone number:
Email

Q.107 Time visit ended: ___ (hh:mm AM/PM) (GO TO END SCREEN MESSAGE 1)
[ASK IF TERMINATE]
Q108. If interview was not possible, what was the main reason?

1.
2.
3.

4.
5.
6.

Participant refused based on concerns over COVID-19 health risks (GO TO END
SCREEN MESSAGE 2)
Participant refused for reasons other than COVID-19 health risks (GO TO END
SCREEN MESSAGE 2)
Participant refused for unclear or unidentified reason(s) (GO TO END SCREEN
MESSAGE 2)
Participant answered “yes” to at least one COVID screening question (symptoms,
quarantine, etc.) (GO TO END SCREEN MESSAGE 2)
Refused entry to building (GO TO END SCREEN MESSAGE 2)
No one home (GO TO END SCREEN MESSAGE 2)

7.
8.
9.
10.
11.
12.
13.
14.
15.

Only a minor was home (GO TO END SCREEN MESSAGE 2)
No smoke and CO alarms in the home & did not take short version (GO TO END
SCREEN MESSAGE 2)
Alarms connected to security system & did not take short version (GO TO END
SCREEN MESSAGE 2)
Participant did not consent to answering survey questions (GO TO END SCREEN
MESSAGE 2)
Participant did not consent to alarm testing portion
(GO TO END SCREEN
MESSAGE 2)
Participant declined Hold Harmless agreement (GO TO END SCREEN MESSAGE 2)
Language barrier (GO TO END SCREEN MESSAGE 2)
Occupant refused entry (Why?): [textbox] (GO TO END SCREEN MESSAGE 2)
Other (specify): [textbox] (GO TO END SCREEN MESSAGE 2)

END SCREEN MESSAGES
Message 1:
(READ) “Thank you very much for helping us with this study. All responses have been recorded.”
[INTEREVIEWER]
Please remember to:

•
•
•

Upload and sync the data on the tablet according to the technical guide
Carefully collect all alarms from this home (if applicable) and EurekaFacts testing
materials
Contact EurekaFacts if you have any questions or concerns

Message 2:
[INTERVIEWER] Participant is not eligible please thank them for their time and continue to next housing unit.
(READ) “Thank you for answering these questions. Unfortunately, we are not able to continue with this interview.
Have a nice day.”
[INTERVIEWER] Please press the “X” on the top right corner of the screen to exit.
When prompted with the option to save your response as partial, select “No”. This will discard the case and end
the interview. See image below:

Appendix I: Programed Qualifiers that result in Abbreviated Survey for Participants without Detectors or with
Detectors Connected to a Security Alarm System

1. IF S.15= “No” AND S.19= No

2. OR IF S.15= “No” AND S.20= “Yes”
3. OR IF S.15= “No” AND S.21= “Yes”
4. OR IF S.15= “No” AND S.21= “Never has a CO …incident”
5.
6.
7.
8.

OR IF S.16= “Yes” AND S.19= No
OR IF S.16= “Yes” AND S.20= “Yes”
OR IF S.16= “Yes” AND S.21= “Yes”
OR IF S.16= “Yes” AND S.21= “Never has a CO …incident”

9. OR IF S.17= “Yes” AND S.19= No
10. OR IF S.17= “Yes” AND S.20= “Yes”
11. OR IF S.17= “Yes” AND S.21= “Yes”
12. OR IF S.17= “Yes” AND S.21= “Never has a CO …incident”
13. OR IF S.17= “Never has a fire …incident” AND S.19= No
14. OR IF S.17= “Never has a fire …incident” AND S.21= “Never has a CO …incident”
15. OR IF S.17= “Never has a fire …incident” AND S.20= “Yes”
16. OR IF S.17= “Never has a fire …incident” AND S.21= “Yes”
Appendix II: Logic resulting in replacement alarm question

1. OR IF Q.50 in the current loop = “Yes” (Faulty sensor, no smoke response but button
sounds)
2. OR IF Q.51 in the current loop= “No” (Combination alarm, CO portion not working)
3. OR IF Q.53 in the current loop= “No” (Participant does not want batteries in nonresponding alarms)
4. OR IF Q.53 in the current loop = “no- 10-year seal...” (Battery is 10 year)
5. IF Q.54 in the current loop = “No” (Battery was replaced, and the detector did not
respond to smoke)
6. OR IF Q.56 in the current loop = “No” (Battery was replaced, and the CO detector did
not respond to button test)

Appendix H: Abbreviated Survey for Participants without Detectors or with
Detectors Connected to a Security Alarm System
2019 U.S. Consumer Product Safety Commission (CPSC) Survey on Usage and Functionality of Smoke and Carbon
Monoxide (CO) Detectors in Households
Abbreviated Survey for Participants without Detectors or with Detectors Connected to a Security Alarm System
Door to Door Campaign 20-minute Instrument (No Alarm or Security Alarm Households)
See APPENDIX l at end of Appendix G (Door to Door Questionnaire) for qualifying combinations.
[INTERVIEWER] This is the survey instrument for participants who do not have a smoke alarm or have alarms that
are connected to a security alarm system.
[Module 16: Abbreviated Survey Consent and Hold Harmless Waiver]
Q.109[INTERVIEWER:] The participant does not have alarms eligible for testing. However, they do qualify for
the “no alarm/security alarm” version of the survey.
[INTERVIEWER:] If “no alarm/security alarm” interviews are needed for survey quotas use the following
script: “Thank you for answering these questions. Since you do not have a detector that we can test or
because we have identified that your alarms will notify first responders, you are not eligible for the 60minute survey in alarm testing study; you are, however, eligible for the 20-minute version of the survey
where you can earn a $10 gift card for answering our brief questionnaire. Would you like to participate in
this survey? “
[INTERVIEWER:] If quota for “no alarm/security alarm” interviews is complete: “Thank you for answering
these questions. Since you do not have a smoke detector that we can test or because we have identified
that your alarms will notify first responders, you are not eligible for this study. Have a nice day”
1.
Yes, I would like to participate in the short survey (CONTINUE)
2.
No, I do not want to participate (GO TO TERMINATION Q.108_F2)
3.
Quotas complete for “no alarm/security alarm” interviews (DO NOT READ) (GO TO TERMINATION
Q.108_F2)
[ASK ALL]
S.24_F2Before we begin, we need you to review a consent form with information about the study.”
“Please read the following off of my tablet. If you agree to allow this interview to proceed, please sign the
bottom. Let me know you have any questions.”
[Interviewer Instructions]
o Go to the next page and hand the tablet to the respondent for them to read and sign
electronically.
o If participant refuses, say thank you and terminate.

S.25_F2 Consumer Product Safety Commission (CPSC) Survey on Usage and Functionality of Smoke Detectors
and Carbon Monoxide Detectors in Households
Informed Consent Form
Thank you for your interest in participating in the research study. This study is conducted by EurekaFacts on behalf
of the U.S. Consumer Product Safety Commission (CPSC). We are conducting a nationwide survey on household
fire and carbon monoxide (CO) safety. The purpose of this study is to gather information about the functionality of
smoke detectors and CO detectors in U.S. households by asking a series of survey questions and testing your
household smoke and CO alarms. Findings from this research will help CPSC improve home safety.
The interview lasts about 20 minutes and you will receive a $10 gift card from a major credit card company in
appreciation for completion of the survey. Our trained and qualified two-member survey team will ask you
questions related to fire and carbon monoxide safety.
Information collected from this study will help CPSC to improve household fire and CO safety. Your input will assist
with developing standards and guidelines that will help protect property and human life. This research does not
involve any foreseeable risks.
Your participation in this research study is completely voluntary. You may stop at any time if you do not want to
continue with the study by notifying a member of the survey team. Your responses will be maintained confidential
and will be used for research purposes only. At no time will any identifiable information be linked to any of your
answers. All information collected through our research process is reported to CPSC anonymously.
S.25a_F2 We ask for your consent to participate in answering questions as part of the survey portion of this study.
1.
2.

I consent
I do not consent (SKIP TO REASON FOR TERMINATION Q.108_F2)

NO QUESTION S.25B_F2
S.25c_F2 Your signature below means that you have freely agreed to participate in this research study. You should
consent only if you have read this document and you understand its contents.
[ASK ALL]
S.26_F2Informed Consent Form {2e-eg}
a.
b.
c.

Signature [Signature box]
Enter Name [Text box]
Date [Textbox]

NO QUESTION S.27_F2

(READ) “Thank you. Your input is very important to this research. Let’s Begin!”
Page Break

[Module 17: ABBREVIATED HOME CHARACTERISTICS]
[ASK ALL]
Q.1_F2Do you or another member of your household own or rent your home? (DO NOT READ LIST)
1.
2.
98.
99.

Own
Rent
Don’t know
Refused

[ASK ALL]
Q.2_F2For how many years have you lived in this (apartment/house)?
1.
98.
99.

Drop down menu of full year integers [Include less than one year]
Don’t know
Refused

[ASK ALL]
Q.3_F2Please tell me to the best of your knowledge, in what year was this (apartment/house) built? Was it …?
(READ LIST) {8}
1.
2.
3.
4.
5.
6.
7.
98.
99.

2010 or later
Between 2000 and 2009
Between 1990 and 1999
Between 1980 and 1989
Between 1970 and 1979
Between 1960 and 1969
Before 1960
Don’t know (DON’T READ)
Refused (DON’T READ)

[IF “Single Family Detached Housing” or “Single Family Attached” (S.2=1-2), ASK:]
Q.4_F2What types of fuel-burning appliances, if any, do you own or have in your home? By fuel burning
appliances, we mean appliances that use gas, propane, oil, wood, wood pellets, coal, or kerosene. Do not
include electric-powered appliances. (READ LIST, SELECT ALL THAT APPLY) {9a}
1.
2.
3.
4.
5.
6.
7.
8.
9.
98.
99.

Gas powered generator
Furnace or boiler
Water heater
Charcoal grill
Gas Dryer
Wood or pellet burning fireplace or stove
Kitchen appliances (e.g., stove, oven)
Other (Specify) [TEXTBOX]
Do not own any fuel-burning appliances [Exclusive]
Don’t know (DON’T READ) [Exclusive]
Refused (DON’T READ) [Exclusive]

[IF “Single Family Detached Housing” or “Single Family Attached” (S.2=1-2), ASK:]
Q.5_F2Does this residence have an attached garage unit? (DO NOT READ LIST) {9b}
1.
2.
98.
99.

Yes
No (SKIP TO Q.9)
Don’t know (SKIP TO Q.9)
Refused (SKIP TO Q.9)

[IF “Single Family Detached Housing” or “Single Family Attached” ( S.2=1-2), ASK:]
[IF “Yes” (Q5_F2=1), ASK]
Q.6_F2For what purposes is the attached garage used? Would you say… (READ LIST, SELECT ALL THAT APPLY)

1.
2.
3.
4.
5.
98.
99.

Workshop/ workspace
Store tools or lawn/ sports equipment
Store vehicle(s) (e.g., motorcycle, car, SUV, van, etc.)
Fuel burning appliances (e.g., furnace, water heater, grill, etc.)
Other (Specify:) [TEXTBOX]
Don’t know
Refused

NO QUESTION Q.7_F2 - Q.8_F2
[Module 18: ABBREVIATED SMOKE DETECTOR BEHAVIORS]
[ASK IF HAS SMOKE DETECTORS, S.15=1:].
Q.9_F2Please tell me to what extent do you believe your home is safe with your current smoke detectors? Would
you say ...
[READ LIST]
1.
2.
3.
4.
5.
98.
99.

Not at all safe
Slightly safe
Moderately safe
Mostly Safe
Very safe
Don’t know (DON’T READ)
Refused (DON’T READ)

NO QUESTION Q.10_F2 – Q.11_F2
[ASK ALL:]
Q.12_F2Do you know how to… (DO NOT READ RESPONSE OPTIONS)
a.
b.

Install a smoke detector?
Maintain a smoke detector in good working order?

[Response Options]
1.
Yes
2.
No
98.
Unsure
99.
Refused
NO QUESTION Q.13_F2
[ASK ALL:].
Q. 14_F2 On a scale of 1 to 5, where 1 is “Not at All Necessary”, and 5 is “Extremely Necessary”, how necessary do
you feel it is to have a smoke detector installed in your home? {Q29}
1.
2.
3.
4.
5.
98.
99.

1 – Not at All Necessary
2
3
4
5 – Extremely Necessary
Don’t Know
Refused

[ASK IF NO SMOKE DETECTOR, S.15=2]

Q.15_F2Please tell me what are some of the reasons you do not have a smoke detector installed in your
home? (DO NOT READ LIST, SELECT ALL THAT APPLY) {Q30}
1.
2.
3.
4.
5.
6.
7.
98.
99.

Don’t think I need one
Did not come with residence
They are a nuisance
They did not or don’t work
Never got around to replacing previous detectors
It is the landlord’s responsibility
Other reason[Textbox]
Don’t know
Refused

[Module 19: FIRE HISTORY]
[ASK ALL:]
Q.16_F2In the past 12 months, have you had any accidental fires – that is unintended or unwanted smoke or
flames - in your home? Please include fires that were too small to call the fire department. (DO NOT READ
LIST)
1.
2.
98.
99.

Yes (CONTINUE)
No (SKIP TO Q.17)
Don’t know (SKIP TO Q.17)
Refused (SKIP TO Q.17)

Page Break

[ASK IF “Yes”, Q16_F2=1:]
Q.16a_F2 Thinking of the most recent accidental fire(s), how did you become alerted to the incident? (DO NOT
READ LIST, SELECT ALL THAT APPLY) {14b}
1.
2.
3.
4.
5.
6.
7.
8.
98.
99.

Saw the fire
Smelled the fire
Heard the fire
Felt the heat of the fire
Smoke detector
Someone notified me
Other (Specify) [textbox]
Don’t remember
Don’t know
Refused

NO QUESTION Q.17_F2 – Q.19_F2
[Module 20: CO DETECTORS]
[ASK IF HAS CO DETECTORS, S.19=1:].
Q.20_F2Please tell me to what extent do you believe your home is safe with your current carbon monoxide
detectors? Would you say... (READ LIST)
[READ LIST]
1.
2.

Not at all safe
Slightly safe

3.
4.
5.
98.
99.

Moderately safe
Mostly Safe
Very safe
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.21_F2How would you know if high levels of carbon monoxide (CO) were present in your home? (DO NOT READ
LIST, SELECT ALL THAT APPLY).
1.
2.
3.
4.
5.
6.
7.
98.
99.

You can smell it
You can taste it
You can see it
You can feel it
Carbon monoxide detector
Other (Specify:) [textbox]
Respondent does not believe there is a way to know if CO is present
Don’t know
Refused

[ASK ALL:]
Q.22_F2How much do you believe you know about carbon monoxide detectors? (READ LIST) {17}
1.
Nothing at all
2.
A little
3.
Some
4.
A lot
98.
Don’t know (DON’T READ)
99.
Refused (DON’T READ)
NO QUESTIONS Q.23_F2 - Q.26_F2
[ASK ALL:].
Q. 27_F2 On a scale of 1 to 5, where 1 is “Not at All Necessary”, and 5 is “Extremely Necessary”, how necessary do
you feel it is to have a carbon monoxide detector installed in your home? {Q31}
1.
2.
3.
4.
5.
98.
99.

1 – Not at all necessary
2
3
4
5 – Extremely Necessary
Don’t Know
Refused

[ASK IF NO CO DETECTOR, S.19=2]
Q.28_F2Please tell me what are some of the reasons you do not have a carbon monoxide detector installed in your
home. (PRECODED LIST. DO NOT READ, SELECT ALL THAT APPLY) {Q32}
1.
2.
3.
4.
5.

Don’t think I need one
Did not come with residence
They are a nuisance
They did not or don’t work
Never got around to replacing previous detectors

6.
7.
98.
99.

It is the landlord’s responsibility
Other reason [Textbox]
Don’t know
Refused

NO QUESTIONS Q.29_F2 - Q.31_F2
[ASK ALL:] 
Q.32_F2 In the past 12 months, were you aware that any of your friends, relatives, neighbors, or coworkers
experienced… (DO NOT READ RESPONSE OPTIONS) {Q24}

a.
An accidental fire?
b.
A carbon monoxide incident? (e.g., effects of carbon monoxide poisoning)
[Response Option]
1.
Yes
2.
No
98.
Unsure
99.
Refused
[MODULE 21: FIRE SAFETY SOURCES]
[ASK ALL:]
Q.33_F2In the past 12 months, have you looked for any information about either fire safety or carbon monoxide
safety, or not? (DO NOT READ LIST)
1.
2.
98.
99.

Yes
No (SKIP TO Q36)
Unsure (SKIP TO Q36)
Refused (SKIP TO Q36)

[ASK IF Q.33_F2=1:]
Q.34_F2Where do you obtain information about fire safety? (READ LIST ONE AT A TIME) (SELECT ALL THAT
APPLY) 
1.
2.
3.
4.
5.
6.
7.
8.
98.
99.

TV news, or radio
Internet search engines like Google
Family or friends
Community or religious organizations
Social media like Facebook
Local fire department
Other (SPECIFY) (DON’T READ) [Textbox]
None of these (DON’T READ)
Don’t know or remember (DON’T READ)
Refused (DON’T READ)

1.
2.

TV news, or radio
Internet search engines like Google

[ASK IF Q.33_F2=1:]
Q.35_F2Where do you obtain information about carbon monoxide safety? (READ LIST ONE AT A TIME) (SELECT
ALL THAT APPLY) 

3.
4.
5.
6.
7.
8.
98.
99.

Family or friends
Community or religious organizations
Social media like Facebook
Local fire department
Other (SPECIFY) (DON’T READ) [Textbox]
None of these (DON’T READ)
Don’t know or remember (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.36_F2How often do you or another member of the household cook at home using a stove or oven? Does a
member of this household cook… (READ LIST)? 
1.
2.
3.
4.
5.
98.
99.

Never
A few times per year
A few times per month 
A few times per week 
Every day 
Don’t know (DON’T READ) 
Refused (DON’T READ) 

NO QUESTION Q.37_F2
[ASK ALL:]
Q.38Please tell me how you would evaluate your home fire safety. Would you say it is… (READ LIST)?
[READ LIST]
1.
2.
3.
4.
5.
98.
99.

Not at all safe
Slightly safe
Moderately safe
Mostly Safe
Very safe
Don’t know (DON’T READ)
Refused (DON’T READ)

Q.39 [OBSERVE] Time: ___ (hh:mm AM/PM)
NO QUESTION Q.40_F2-Q.84_F2
[MODULE 22: DEMOGRAPHICS]
Great! To ensure that we interview a broad mix of residents, I have a few brief demographic questions to ask
about you and others within the household. It should only take a few minutes of your time.
[ASK ALL:]
Q.85_F2How many people live or stay in your household? This can include:
o Anyone who is living or staying here for more than 2 months
o Yourself, if you are living here for more than 2 months
o Anyone else staying here who does not have another place to stay, even if they are here for 2
months or less

Please do not include anyone who is living somewhere else for more than 2 months, such as a college student
living away or someone in the Armed Forces on deployment. 
1.

Enter number of people

[ASK ALL:]
Q.86_F2Thinking of the individual(s) who live here, including yourself, is there anyone… (INSERT ITEM)
a.
b.
c.
d.
e.
f.
g.
h.

Under 5 years old
5-9 years old
10-14 years old
15-19 years old
20 to 34 years old
35 to 54 years old
55 to 64 years old
65 years old or older

RESPONSE OPTIONS
1.
Yes
2.
No
98.
Don’t know (DON’T READ)
99.
Refused (DON’T READ)
NO QUESTIONS 87_F2-90_F2
[ASK ALL:]
Q.91_F2Thinking of the individual(s) who live here, including yourself, how many are … (INSERT ITEM) {37a}
[Carry forward any Q90_F2=1]
a.
Under 5 years old
b.
5-9 years old
c.
10-14 years old
d.
15-19 years old
e.
20 to 34 years old
f.
35 to 54 years old
g.
55 to 64 years old
h.
65 years old or older
RESPONSE OPTIONS
1.
Enter number of people
[ASK ALL:]
Q.92_F2What is the highest level of education you have completed or the highest degree you have received? (DO
NOT READ LIST)
1.
2.
3.
4.
5.
6.

Less than high school, no diploma
High school diploma, or high school equivalent (GED)
Trade or Vocational school degree
Some college, no degree
Associate degree
Bachelor’s degree

7.
98.
99.

Master’s degree or higher
Don’t know
Refused

[ASK ALL:]
Q.93_F2Are you of Hispanic, Latino, or Spanish origin, such as Mexican, Puerto Rican or Cuban? (DO
NOT READ LIST)
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.94_F2What is your race? (SELECT ALL THAT APPLY)
1.
White
2.
Black or African American
3.
Asian
4.
American Indian or Alaska Native
5.
Native Hawaiian or other Pacific Islander
6.
Some Other Race (Specify) [TEXTBOX]
7.
Hispanic/Latino (e.g., Mexican, Puerto Rican, Cuban)
98
Don’t know (DON’T READ)
99Refused (DON’T READ)
[IF NOT HISPANIC (Q93=2-99), ASK:]
Q.95_F2Is anyone in the household of Hispanic or Latino origin or descent? (DO NOT READ LIST)
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.96_F2Is anyone in the household deaf or hard of hearing? (DO NOT READ LIST)
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.97_F2Does anyone in the household have a physical, mental, or other health condition that has lasted 6 or more
months which makes it difficult for them to carry out day to day activities? (DO NOT READ LIST)
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.98_F2Do any people in the home smoke cigarettes, cigars, hookahs, or pipes? Please do not include e-cigarettes
or vaping devices. (DO NOT READ LIST)
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK ALL:]
Q.99_F2In the last 12 months, what was your total household income from all sources, before taxes? Just stop me
when I get to the right category. (READ LIST) (If necessary, read)
1.
2.
3.
4.
5.
6.
7.
8.
9.
98.
99.

Less than $15,000 
$15,000 to under $25,000 
$25,000 to under $35,000 
$35,000 to under $50,000 
$50,000 to under $75,000 
$75,000 to under $100,000 
$100,000 to under $150,000 
$150,000 to under $200,000 
$200,000 or more 
Don’t know (DON’T READ) 
Refused (DON’T READ) 

Q.100_F2 [OBSERVE:] Time visit ended: ___ (hh:mm AM/PM)
NO QUESTIONS 101_F2-103_F2
[MODULE 23: INCENTIVE]
[ASK ALL:]
Q.104_F2 Incentive Form
[INTERVIEWER:] Important Note. Do not hand participant gift card until you have verified their
information.
(READ) “Thank you so much for participating in this survey. Your answers will help CPSC with improving
household fire and CO safety across the U.S. As a token of our appreciation for completing the
survey, EurekaFacts would like to provide you with this $10 gift card.”
(READ) “Please verify that the following information is correct.”
[INTERVIEWER: Show participant the next page and once all information is confirmed provide incentive
card. Have participant sign receipt of card.
[PIPPED IN FIRST NAME FROM CONSENT FORM]
[PIPPED IN LAST NAME FROM CONSENT FORM]
[PIPPED IN STREET ADDRESS]
[PIPPED IN APT/SUITE #]
[PIPPED IN CITY], [PIPPED IN STATE] [PIPPED IN ZIP CODE]
I acknowledge that all this information is correct and that my $10 gift card for completing the CPSC Inhome Smoke and CO Study has been provided.

Signature
[ASK ALL:]
Q.105_F2 At a later date, CPSC may want to talk further with people who took part in this survey. Would you be
willing to talk to them about the survey at a convenient time in the future?
1.
2.
98.
99.

Yes
No
Don’t know (DON’T READ)
Refused (DON’T READ)

[ASK IF Q.105_F2=1:]
Q.106_F2 So that someone can reach you more easily, I just need to confirm your name, best phone number and
email address.
1.
2.
3.

Name:
Best phone number:
Email:

Q.107_F2 Time visit ended: ___ (hh:mm AM/PM) (GO TO END SCREEN MESSAGE 1)

[ASK IF TERMINATE]
Q108_F2. If interview was not possible, what was the main reason?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Participant refused based on concerns over COVID-19 health risks (GO TO END SCREEN MESSAGE 2)
Participant refused for reasons other than COVID-19 health risks (GO TO END SCREEN MESSAGE 2)
Participant refused for unclear or unidentified reason(s) (GO TO END SCREEN MESSAGE 2)
Refused entry to building (GO TO END SCREEN MESSAGE 2)
No one home (GO TO END SCREEN MESSAGE 2)
Only a minor was home (GO TO END SCREEN MESSAGE 2)
No smoke and CO alarms in the home (GO TO END SCREEN MESSAGE 2)
Alarms connected to security system (GO TO END SCREEN MESSAGE 2)
Participant did not consent to answering survey questions (GO TO END SCREEN MESSAGE 2)
Participant did not consent to alarm testing portion (GO TO END SCREEN MESSAGE 2)
Language barrier (GO TO END SCREEN MESSAGE 2)
Occupant refused entry (Why?): [textbox] (GO TO END SCREEN MESSAGE 2)
Other (specify): [textbox] (GO TO END SCREEN MESSAGE 2)

END SCREEN MESSAGES
Message 1:
(READ) “Thank you very much for helping us with this study. All responses have been recorded.”
[INTEREVIEWER]
Please remember to:
• Upload and sync the data on the tablet according to the technical guide

•
•

Carefully collect all alarms from this home (if applicable) and EurekaFacts testing materials
Contact EurekaFacts if you have any questions or concerns

Message 2 :
[INTERVIEWER] Participant is not eligible please thank them for their time and continue to next housing unit.
(READ) “Thank you for answering these questions. Unfortunately, we are not able to continue with this interview.
Have a nice day.”