CHNN01 poisoning over 5

INCIDENT INVESTIGATION ASSIGNMENT INSTRUCTIONS
Poisonings/Chemical Injuries Involving Children 5 Years and Older
DOCUMENT NUMBER:
DATE OF INCIDENT:

CATID: CHNN01 2020

FOLLOW-UP REQUESTED

HAZARD ANALYSIS

COMPLIANCE

PRIMARY CONTACT: Cheryl Scorpio, HS, 301-987-2572, [email protected]
BACK-UP CONTACT: Angie Qin, EPHA, 301-504-7810, [email protected]
ASSIGNMENT MESSAGE:

Determine if the respondent is the victim, is the parent of an injured child under 18, or is involved in
another capacity (specify). Determine if the respondent witnessed the incident. Describe the incident
scenario, any subsequent treatment, and the resolution of the injury (recovered fully, partial recovery,
etc.). If fatal, life-threatening, or resulting in permanent disability, collect all official documentation.
Determine the brand name and/or model number, manufacturer, place of purchase, and age of the product.
Determine product formulation (liquid, powder, pill, capsule, cream, gel, etc.). Determine about how
much the victim ingested, spilled, or otherwise contacted (skin or eye contact). Describe the container
and ask whether container/product would be easy for a young child to open. Ask whether the container is
still available, and if it is available, obtain photographs, including all labeling information. If possible,
obtain the product.
For further information, contact Cheryl Scorpio, 301-987-2572. A telephone questionnaire is available
for interview guidelines; contact Cheryl if you would like a copy.
Please include all primary and all backup contacts in the distribution of the completed IDI.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Area below will be completed in Data Systems _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Person(s) to Contact:
Guidelines:
Task Number:
Assigned to:

CPSC FORM 324A

Date:
Processed by: lew

CHILDREN’S POISONINGS QUESTIONNAIRE for CHILDREN AGES 5 and OLDER

TASK NUMBER: ________________________________________ EXHIBIT NUMBER: ____________
Q.1 General Instructions:
Bold type indicates what should be said to the respondent. Instructions for the interviewer will be
prefaced by “Interviewer:” and are written in non-bold type.
Interviewer: Please do not read choices or give examples unless the respondent is unsure, then
you can prompt. Do not read the “Refused” or “Unknown” choices.

Q.2 Interviewer: Please enter the task number and incident date.
Task Number:

__________________________

Incident date (mm/dd/yyyy): ________________

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




1
2

Yes
No

[Interviewer: IF THE ANSWER IS YES, SKIP TO QUESTION 5]

Q.4 Could I speak to another available adult who is familiar with the recent incident?




1
2

Yes
No

[Interviewer: IF THE ANSWER IS YES, ASK TO SPEAK TO THAT PERSON.]
[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 31]

Q.5 What is your relationship with the patient?

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Parent
Guardian other than parent
3 Other
1
2

[Interviewer: IF THE ANSWER IS PARENT or GUARDIAN, SKIP TO QUESTION 7]

CPSC FORM 324A

Q.6 Please identify “Other” relationship. ________________________________________
Q.7 Do you have a few minutes to talk about the incident?
Interviewer: The interview should take about 10 minutes.

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

Yes
2 No
1

[Interviewer: IF THE ANSWER IS YES, SKIP TO QUESTION 9]

Q.8 Can I call you back at a better time?




1
2

Yes
No

[Interviewer: IF THE ANSWER IS YES, THEN ASK THEM TO SPECIFY A BETTER TIME: ___________
THEN SKIP TO QUESTION 28]
[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 31]

Q.9 Did you witness the incident?




1
2

Yes
No

Q. 10 Please give a brief summary of the reason for the emergency room visit:
Interviewer: If not provided, please probe for the following information.
- Where was the child when the incident occurred? Kitchen, bathroom, etc.
- Was another child involved? What was the age of the other child?
- How did the child access the medication/product?
- Where was the medication/product stored?
- Was someone using the medication/product at the time of the incident?
- Had the medication/product spilled or had the packaging been damaged/broken just
prior to the exposure?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

CPSC FORM 324A

Please describe the symptom(s) experienced by the victim, any treatment(s), and the outcome of
the exposure:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Q.11 Please describe the type of exposure that occurred in this incident.
Interviewer: Choose all that apply

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Ingestion
Skin
3 Eye
4 Mouth (inside, not swallowed) &/or lips
5 Other
1
2

Q.12 Suggest this question: What type of product formulation was involved in the exposure?

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Liquid
2 Pills, tablets, or capsules
3 Oral disintegrating or rapid dissolve tablet or film
4 Other
5 Don’t know
1

Q 13. Please identify “Other” formulation. (Interviewer: Other product types include transdermal
patches, creams/ointments, sprays, powders/granules, medicated lollipops, etc.)
_____________________________________________

Q.14 What is the brand name and/or manufacturer, package size (how many), dosage (e.g. 10mg)?
Interviewer: Get information for each product ingested, possibly ingested, spilled, sprayed, etc.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Q.15 How much would you estimate the child ate, drank, spilled, sprayed, etc. of each product?
Interviewer: Get information for each product ingested, possibly ingested, or spilled/sprayed on/in the
skin, eye, etc.
______________________________________________________________________________________
______________________________________________________________________________________

CPSC FORM 324A

Q.16 Was the product in a bottle, some other kind of container, or not in any container at all?

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Bottle
Daily or weekly pill holder or pill minder?
3 Other container
4 No container
5 Don’t know
1
2

[Interviewer: IF THE ANSWER IS BOTTLE, SKIP TO QUESTION 22]
[Interviewer: IF THE ANSWER IS OTHER CONTAINER, SKIP TO QUESTION 20]
[Interviewer: IF THE ANSWER IS NO CONTAINER, SKIP TO QUESTION 31]
[Interviewer: IF THE ANSWER IS DON’T KNOW, SKIP TO QUESTION 31]

Q.17 Please describe the pill holder/minder. Where was it located?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Q.18 Were other medications also stored in the pill holder/minder?

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
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Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NO or DON’T KNOW, SKIP TO QUESTION 31]

Q.19 Please describe the other medications in the pill holder/minder.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
[Interviewer: SKIP TO QUESTION 31]

Q.20 Please specify the other container.
Interviewer: Possibilities include a plastic or paper bag, pocket, pocketbook, etc.
______________________________________________________________________________________
[Interviewer: SKIP TO QUESTION 31]

CPSC FORM 324A

Q.21 Please explain why the product was out of any container.
Interviewer: Possibilities include product spilled, in use, left available on a countertop, an older child
accessed and gave to victim, etc.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
[Interviewer: SKIP TO QUESTION 31]

Q.22 Was the container tightly closed, somewhat closed, or not closed at all?

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Tightly closed
Somewhat closed
3 Not closed at all
4 Don’t know
1
2

Q.23 Was the package/container child-resistant, that is, one that would be hard for a child to
open?





Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NO or DON’T KNOW, SKIP to QUESTION 31]

Q.24 How long was the child alone with the child-resistant package/container?





Less than 10 minutes
Greater than 10 minutes
3 Don’t know
1
2

Q.25 If the product was a liquid, did the package/container have a flow-restrictor on its opening?
(A flow restrictor is a small plastic device that fits into the neck of a medicine bottle and slows the release
of the fluid.)





Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NO or DON’T KNOW, SKIP to QUESTION 31]

Q.26 Please describe the flow restrictor type. Could it be easily removed from the
package/container or was it permanently attached or part of the package container
opening/design? Was a syringe required to remove the medication?
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______________________________________________________________________________________

CPSC FORM 324A

Q.27 Was the product a:

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Prescription medication
Over-the-counter medication
3 Household chemical
4 Other
1
2

Q.28 Please identify the source of the product or where it was purchased (e.g., pharmacy name,
retail store, etc.)
_______________________________________________

Q.29 Do you still have the container?





Yes
2 No
3 Don’t know
1

[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 31]

Q.30 Would you be willing to send us the container, if we mail you a shipping envelope that is selfaddressed and stamped?




1
2

Yes
No

[Interviewer: If the answer is yes, Investigator should collect container as a sample.]

Q.31 Due to the cultural diversity in the U.S., we sometimes have difficulty communicating
important product safety information to consumers. The following race and ethnicity questions
will help us to better educate the public on consumer product safety.
Do you consider the patient to be Hispanic or Latino?

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CPSC FORM 324A

Yes
2 No
3 Unknown
4 Refuse to answer
1

Q.32 What race or races do you consider the patient to be?
Interviewer: Please read race choices aloud and ask respondent to select ALL categories that
apply. If the answer is “Other” enter their answer verbatim in the next question (Q.33).

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White
Black or African American
3 American Indian or Alaska Native
4 Native Hawaiian or Pacific Islander
5 Asian
6 Other
7 Unknown
8 Refuse to answer
1
2

[Interviewer: IF THE ANSWER IS NOT OTHER, THEN SKIP TO QUESTION 34]

Q.33 Please specify “Other” race.
Interviewer: If respondent states “biracial” or “multiracial”, please prompt for specifics (country of
origin, nationality, etc.). Otherwise, simply state “biracial” or “multiracial”.
______________________________________________________________________________________

Q.34 On behalf of the Consumer Product Safety Commission, I thank you very much for your help.
If I missed anything, may I call you back?

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

1
2

Yes
No

Q.35 Thank you for your time.

Q.36 Interviewer: Enter the interview completion date: ________________ (mm/dd/yyy)

CPSC FORM 324A