CHNN08 poisoning under 5

INCIDENT INVESTIGATION ASSIGNMENT INSTRUCTIONS
Poisonings/Chemical Injuries Involving Children less than 5
DOCUMENT NUMBER:
DATE OF INCIDENT:

CATID: CHNN08 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:

Information from this investigation will be used to support activity under the Poison Prevention
Packaging Act (PPPA). In addition to the general guidelines described below, a telephone
questionnaire accompanies this assignment message. Specifically address all questions not
crossed out.
Describe the accident scenario, symptoms, time after contact symptoms started, any subsequent
medical treatment, and the resolution of the injury (recovered fully, partial recovery, etc.).
Determine product information (liquid, powder, pill, capsule, cream, gel, etc.). Describe amount
ingested, spilled, or otherwise contacted (skin or eye contact). 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 all
products involved in the accident. Describe product container and closure in detail and
photograph if possible (e.g., was it child resistant or not, if it was properly closed, where stored,
if chemical was transferred to a different container than it was purchased in). If possible, obtain
the product or, if there is an indication of CR packaging failure, collect a similar sample and
forward to Mark Eilbert, LSM, 301-987-2232, [email protected], for evaluation.
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 LESS THAN 5 YEARS OLD

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]?

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

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?
Interviewer: If the response is yes, ask to speak to that person.

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

1
2

Yes
No

[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 32]

Q.5 What is your relationship with the patient?

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Parent
Guardian other than parent
3 Other
[Interviewer: IF THE ANSWER IS NOT OTHER, SKIP TO QUESTION 7]

CPSC FORM 324A

1
2

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?

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

1
2

Yes
No

[Interviewer: IF THE ANSWER IS YES, THEN ASK THEM TO SPECIFY A BETTER TIME: ___________
THEN SKIP TO QUESTION 36]
[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 36]

Q.9 Did you witness the incident?

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

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?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
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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 Other
4 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?
Interviewer: Get the 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 the 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 32]
[Interviewer: IF THE ANSWER IS DON’T KNOW, SKIP TO QUESTION 32]

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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Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NOT YES, SKIP TO QUESTION 32]

Q.19 Please describe the other medications in the pill holder/minder.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
[Interviewer: SKIP TO QUESTION 32]

Q.20 Please specify the other container.
Interviewer: Possibilities include a plastic or paper bag, pocket, pocketbook, etc.
______________________________________________________________________________________
[Interviewer: SKIP TO QUESTION 32]

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 32]

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?

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Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NO, SKIP to QUESTION 31]
[Interviewer: IF THE ANSWER IS DON’T KNOW, SKIP to QUESTION 32]

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

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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)

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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 32]

CPSC FORM 324A

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?
______________________________________________________________________________________
______________________________________________________________________________________

Q.27 Was the product a:

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Prescription medication
Over-the-counter medication
3 Household chemical
4 Other. If “Other,” identify the type of “other” product, if known: ___________________________
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?

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Yes
No
3 Don’t know
1
2

[Interviewer: IF THE ANSWER IS NO, SKIP TO QUESTION 32]

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

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

1
2

Yes
No

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

Q.31 If the package/container was NOT child-resistant, was non-child-resistant packaging
requested from the pharmacy?

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CPSC FORM 324A

Yes
No
3 Don’t know
1
2

Q.32 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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Yes
No
3 Unknown
4 Refuse to answer
1
2

Q.33 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 Question 34 ).

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White
2 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

[Interviewer: IF THE ANSWER IS NOT OTHER, THEN SKIP TO QUESTION 35]

Q.34 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.35 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.36 Thank you for your time.

Q.37 Interviewer: Enter the interview completion date: ________________ (mm/dd/yyy)

CPSC FORM 324A