Follow-Up Activities for Product-Related Injuries-Interviews

Telephone CATI Questionnaire for Children's Clothing Ignition

Questionnaire # ________ (1-4)

Q.1 This questionnaire should be implemented on or before June 19, 2015. It contains 3 additional
questions regarding the victim's recovery.
Victims in these NEISS cases were reported to be under age 15, so a parent/guardian will be asked
to complete the interview.
Bold type indicates what should be said to the respondent. Instructions for the interviewer will be
prefaced by "Interviewer:" and given in non-bold type.
Do not read choices unless instructed to in the question. Never read the choice "Don't Know".
Before contacting the victim, please review the NEISS emergency room information for the case and
complete the next 3 questions in advance of making the call. Please note the victim's name and use
it to identify the victim throughout the interview.
Please maximize the Survey System window to view questions in the best formatting.

Q.2 Interviewer: Complete before dialing.
Enter Task Number (13 characters):
__________________________

(5-17)

Q.3 Interviewer: Complete before dialing.
Enter Treatment Date, to be used in Introduction (Ex: October 10, 2012):
__________________________________________________

(18-42)

Q.4 Interviewer: Complete before dialing.
Is Product Code 1313 - Fireworks coded for this NEISS case?
(43)

q 1 Yes
q 2 No

Q.5 Hello, may I speak with a parent or guardian of [victim's name]?
Hello, I'm [interviewer name] from [contracting agency]. We are working with the U.S.
Consumer Product Safety Commission or "CPSC" to learn more about fire and burn hazards
involving children's clothing.
I'd like to ask you a few questions about [victim's name]'s visit to the emergency room on
[ANSWER TO Q. 3], so that we can prevent similar injuries in the future. Your participation is
voluntary and your identity and answers will be kept completely confidential. Will you help us?
(44)

q 1 Yes - Continue
q 2 No - Refusal
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 115]

Q.6 I understand that [victim's name] was treated in the emergency room for an injury caused by
clothing that caught on fire, smoldered, or melted. Is that correct?
(45)

q 1 Yes - Continue
q 2 No clothing involved
q 3 No burning/fire involved
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 8]

Q.7 Can you tell me what actually happened?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

[IF THE ANSWER TO QUESTION 6 IS 2 OR 3, THEN SKIP TO QUESTION 115]

(46-545)

Q.8 What is your relationship to [victim's name] ?
(546)

q 1 Parent
q 2 Other
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 10]

Q.9 Interviewer: Specify respondent's "Other" relationship to the victim.
_________________________________________________________________________________

(547-596)

Q.10 Did you witness the incident that prompted [victim's name] to go to the emergency room?
(597)

q 1 Yes
q 2 No

Q.11 Please tell me to the best of your knowledge how the incident happened and what injuries
[victim's name] received.
________________________________________________________________________________

(598-1797)

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Q.12 How old was the child when the incident occurred?
Interviewer: Be sure to label the age given. Ex: 3 days old, 4 months old, 10 1/2 years old, almost 13
years old.
____________________________________________________________

(1798-1827)

Q.13 What was the child's approximate height when the incident occurred?
Interviewer: Be sure to label the measurement given. Ex: 3 1/2 ft., 25 in., 1 meter.
____________________________________________________________

(1828-1857)

Q.14 About how much did child weigh when the incident occurred?
Interviewer: Be sure to label the measurement given. Ex: 15 lbs., 13 kg.
____________________________________________________________

(1858-1887)

Q.15 What was the extent of the injury? That is, how did the doctor characterize the burns
suffered, in terms of percentage of body surface burned and whether the burns were 1st, 2nd,
or 3rd degree?
Did the doctor specify whether the burns were partial thickness or full thickness burns?
_______________________________________________________________________________

(1888-2137)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Q.16 Did [victim's name] receive any additional treatment from a medical professional (such as a
doctor or nurse) after treatment in the emergency room?
(2138)

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

Q.17 What kind of additional treatment did [victim's name] receive?
Interviewer: Enter all that apply.
(2139-2144)

q1
q2
q3
q4
q5
q6
q7

Check up, cleaning, remove bandages, stitches
Plastic or reconstructive surgery, skin grafts
Other surgery
Pressure garments
Physical therapy
Other
Don't Know

[IF THE ANSWER TO QUESTION 17 IS NOT 3, THEN SKIP TO QUESTION 19]

Q.18 Interviewer: Specify "Other" surgery.
_______________________________________________________________________________

(2145-2244)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 17 IS NOT 6, THEN SKIP TO QUESTION 20]

Q.19 Interviewer: Specify "Other" treatment(s).
_______________________________________________________________________________
_______________________________________________________________________________

Q.20 Where did [victim's name] get this treatment?
Interviewer: Read choices and enter all that apply.
(2345-2351)

q1
q2
q3
q4
q5
q6
q7
q8

Same hospital where [victim's name] went to the emergency room
Another hospital
Walk-in clinic
Private physician's office
HMO facility
At home
Other
Don't Know

[IF THE ANSWER TO QUESTION 20 IS NOT 2, THEN SKIP TO QUESTION 22]

(2245-2344)

Q.21 What was the name of the "other hospital" where [victim's name] received treatment?
_______________________________________________________________________________

(2352-2451)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 20 IS NOT 7, THEN SKIP TO QUESTION 23]

Q.22 Please describe the "Other" location where [victim's name] received treatment.
_______________________________________________________________________________

(2452-2551)

_______________________________________________________________________________

Q.23 Was [victim's name] admitted to a hospital or other medical facility at any time due to this
incident?
(2552)

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

Q.24 How many hospitalizations has [victim's name] had due to this incident?
Interviewer: Enter a number from 1 to 99.
# Hospitalizations (1 - 99)

____ (2553-2554)

Q.25 What was the name of the facility where [victim's name] was first admitted?
_______________________________________________________________________________
_______________________________________________________________________________

(2555-2654)

Q.26 What type of facility was it?
Interviewer: Read choices.
(2655)

q1
q2
q3
q4
q5

Burn hospital or hospital with a special burn ward
Other hospital
Rehabilitation/nursing home
Other
Don't Know

[IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 28]

Q.27 Please describe what "Other" kind of facility it was.
_______________________________________________________________________________

(2656-2755)

_______________________________________________________________________________

Q.28 How many nights did [victim's name] stay at that facility?
Interviewer: Enter a number from 1 to 99.
# Nights (1 - 99)

____ (2756-2757)

Q.29 Is [victim's name] still in this facility?
(2758)

q 1 Yes
q 2 No
[IF THE ANSWER TO QUESTION 24 IS 1, THEN SKIP TO QUESTION 37]

Q.30 Where was [victim's name's] next hospitalization?
_______________________________________________________________________________
_______________________________________________________________________________

(2759-2858)

Q.31 What type of facility was it?
Interviewer: Read choices.
(2859)

q1
q2
q3
q4
q5

Burn hospital or hospital with a special burn ward
Other hospital
Rehabilitation/nursing home
Other
Don't Know

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

Q.32 Please describe what "Other" kind of facility it was.
_______________________________________________________________________________

(2860-2959)

_______________________________________________________________________________

Q.33 How many nights did [victim's name] stay at that facility?
Interviewer: Enter a number between 1 and 99.
# Nights (1 - 99)

____ (2960-2961)

Q.34 Is [victim's name] still in this facility?
(2962)

q 1 Yes
q 2 No
[IF THE ANSWER TO QUESTION 24 IS 1 OR 2, THEN SKIP TO QUESTION 37]

Q.35 Please tell me the locations of each of [victim name's] other hospitalizations, the types of
facilities they were, and the number of nights [victim name] stayed in each facility.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 24 IS 1 OR 2, THEN SKIP TO QUESTION 37]

(2963-3212)

Q.36 Is [victim name] still hospitalized?
(3213)

q 1 Yes
q 2 No

Q.37 Do you think [victim's name] will need more treatment?
(3214)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 39]

Q.38 What kind of treatment?
_______________________________________________________________________________

(3215-3314)

_______________________________________________________________________________

Q.39 Has [victim's name] fully recovered from the injury?
(6964)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 41]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 42]

Q.40 How long did it take [victim's name] to recover from the injury?
Interviewer: Please record a numeric value and unit of time, e.g., 2 weeks, 6 months.
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 39 IS 1, THEN SKIP TO QUESTION 42]

(6965-7019)

Q.41 How long from the injury will it take [victim's name] to fully recover? Interviewer: Please record
a numeric value and unit of time, e.g., 8 weeks, 6 months.
_______________________________________________________________________________

(7020-7074)

Q.42 Please describe any long-term effects of the injury, including any permanent loss of function
or activity restriction.
_______________________________________________________________________________

(3315-3464)

_______________________________________________________________________________

Q.43 Did this injury cause you or another adult involved to lose any days/hours of work or school?
(3465)

q1
q2
q3
q4

Missed Work
Missed School
No Missed Work or School
Don't Know

[IF THE ANSWER IS 3 OR 4, THEN SKIP TO QUESTION 45]

Q.44 How much time was lost?
Interviewer: Be sure to label the length of time given by the respondent (months, days, hours, etc.).
_______________________________________________________________________________

(3466-3515)

Q.45 Did this injury cause [victim's name] to lose any days/hours of work or school?
(3516)

q1
q2
q3
q4

Missed Work
Missed School
No Missed Work or School
Don't Know

[IF THE ANSWER IS 3 OR 4, THEN SKIP TO QUESTION 47]

Q.46 How much time was lost?
Interviewer: Be sure to label the length of time given by the respondent (months, days, hours, etc.).
_______________________________________________________________________________

(3517-3566)

Q.47 Now I would like to ask you about some specifics concerning the incident and how it
happened.
What did [victim's name] do upon noticing that the clothing had ignited? Interviewer: Enter all
that apply.
(3567-3571)

q1
q2
q3
q4
q5
q6

Ran to another location
Tried to pat flames out
Tried to remove the clothing
Dropped and rolled
Other
Don't Know

[IF THE ANSWER IS NOT 5, THEN SKIP TO QUESTION 49]

Q.48 Interviewer: Specify "Other" action of the victim.
_______________________________________________________________________________
_______________________________________________________________________________

(3572-3671)

Q.49 How was the fire extinguished?
Interviewer: Enter all that apply.
(3672-3675)

q1
q2
q3
q4
q5

Water
Fire extinguisher
Smothered with blanket, etc.
Other
Don't Know

[IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 51]

Q.50 Interviewer: Specify "Other" method that extinguished the fire.
_______________________________________________________________________________

(3676-3775)

_______________________________________________________________________________

Q.51 Did [victim's name] suffer from any sort of medical condition that may have contributed to the
incident or reduced reaction time?
(3776)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 53]

Q.52 Interviewer: Specify the medical condition.
_______________________________________________________________________________
_______________________________________________________________________________

(3777-3876)

Q.53 Was [victim's name] under the influence of any medication or drugs at the time of the
incident?
(3877)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 55]

Q.54 Interviewer: Specify drugs or medications.
_______________________________________________________________________________
_______________________________________________________________________________

(3878-3977)

Q.55 Now I'd like to ask you about the clothing involved in the incident.
What type of garment ignited, smoldered, or melted?
Interviewer: Scroll down to view all 27 choices. Enter all that apply. Enter 2-digits for each response
(ex: "01" for Infant Wear - Sleeper).
(3978-4031)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13
q 14
q 15
q 16
q 17
q 18
q 19
q 20
q 21
q 22
q 23
q 24
q 25
q 26
q 27

Infant Wear - Sleepwear (may or may not enclose feet)
Infant Wear - Playwear
Infant Wear - Underwear (ex:undershirt, onesie w/ snap under crotch)
Infant Wear - Diaper
Infant Wear - Other
Infant - Blanket Sleeper (see photo; in heavy fabrics like fleece)
T-shirt - Daywear
T-shirt - Underwear
Pants
Jeans
Underpants
Robe
Dress
Blouse
Shirt
Sweater
Sweatshirt
Sweatpants
Leggings
Long underwear - Printed/Decorated
Long undewear - Undecorated
Nightgown
Pajama top - Short sleeves
Pajama top - Long sleeves
Pajama bottom - Short pants
Pajama bottom - Long pants
Other garment

[IF THE ANSWER TO QUESTION 55 IS NOT 5, THEN SKIP TO QUESTION 58]

Q.56 Interviewer: Specify "Other Infant Wear".
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 55 IS NOT 27, THEN SKIP TO QUESTION 58]

(4032-4131)

Q.57 Interviewer: Specify "Other" garment.
_______________________________________________________________________________

(4132-4231)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 120 IS NOT 1-99, THEN SKIP TO QUESTION 59]

Q.58 Which piece of clothing ignited first?
_______________________________________________________________________________

(4232-4281)

Q.59 What part of the garment ignited first?
Interview: If respondent sounds unsure, prompt with examples: sleeve of a shirt, hem of a dress, etc.
_______________________________________________________________________________
_______________________________________________________________________________

Q.60 How did the garment burn?
Interviewer: Read choices and enter all that apply.
(4382-4386)

q1
q2
q3
q4
q5
q6

Surface flash
Rapidly spreading fire
Melted and dripped
Smoldered
Other
Don't Know

[IF THE ANSWER IS NOT 5, THEN SKIP TO QUESTION 62]

(4282-4381)

Q.61 Specify "Other" way garment burned.
_______________________________________________________________________________

(4387-4486)

_______________________________________________________________________________

Q.62 How frequently did the victim wear this garment for sleeping?
(4487)

q1
q2
q3
q4

Usually
Sometimes
Never
Don't Know

Q.63 What was the garment made of?
Interviewer: If respondent sounds unsure, read choices.
(4488)

q1
q2
q3
q4
q5

100% Cotton
Cotton blend
Synthetic fabric
Other
Don't Know

[IF THE ANSWER IS 5, THEN SKIP TO QUESTION 67]

[IF THE ANSWER TO QUESTION 63 IS NOT 4, THEN SKIP TO QUESTION 65]

Q.64 Interviewer: Specify "Other" garment material.
_______________________________________________________________________________
_______________________________________________________________________________

(4489-4588)

Q.65 How did you determine what the garment was made of?
Interviewer: If respondent sounds unsure, read choices.
(4589)

q1
q2
q3
q4

From the tag
From the memory of the victim or incident witness
From a general knowledge of fabrics
Other

[IF THE ANSWER IS NOT 4, THEN SKIP TO QUESTION 67]

Q.66 Interviewer: Specify "Other" way respondent knew what the garment was made of.
_______________________________________________________________________________

(4590-4689)

_______________________________________________________________________________

Q.67 Would you be able to obtain the garment now, while I wait, in order to read what the tag
says?
(4690)

q 1 Yes
q 2 No
q 3 Other
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 70]

[IF THE ANSWER TO QUESTION 67 IS NOT 3, THEN SKIP TO QUESTION 69]

Q.68 Interviewer: Specify "Other" response.
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 67 IS 2, THEN SKIP TO QUESTION 70]

(4691-4790)

Q.69 Interviewer: If garment obtained, record wording of the garment tag; otherwise enter "N/A".
_______________________________________________________________________________

(4791-4890)

_______________________________________________________________________________

Q.70 Was the garment fabric knit or woven?
Interviewer: If respondent sounds unsure, prompt with the explanations below.
Knit fabrics stretch because they are formed by interlooping yarns. Examples include jersey, mesh, tshirts, sweaters,and fleece.
Woven fabrics do not stretch because their fibers are woven at 90 degree angles to one another.
Examples include linen, denim, twill, satin, chiffon, corduroy, flannel, tweed, and canvas.
(4891)

q 1 Knit
q 2 Woven
q 3 Don't Know

Q.71 How would you describe the fit of the garment?
(4892)

q 1 Snug fitting
q 2 Loose fitting
q 3 Don't Know

Q.72 Interviewer: Record any respondent comments about fit. If none, enter "N/A".
_______________________________________________________________________________
_______________________________________________________________________________

(4893-4992)

Q.73 What was the garment size?
Interviewer: If respondent sounds unsure, prompt with examples: 4T, 12, S, XL.
____________________________________________________________

(4993-5022)

Q.74 Was the garment a children's or an adult's size?
(5023)

q1
q2
q3
q4

Children's
Adult's
Other
Don't Know

[IF THE ANSWER IS NOT 3, THEN SKIP TO QUESTION 76]

Q.75 Interviewer: Specify "Other" sizing.
_______________________________________________________________________________

(5024-5073)

Q.76 Who was the manufacturer?
_______________________________________________________________________________
_______________________________________________________________________________

Q.77 How old was the garment at the time of the incident?
Interviewer: If respondent sounds unsure, read choices.
(5174)

q1
q2
q3
q4

First time victim wore it
At most one year old
More than one year old
Don't Know

(5074-5173)

Q.78 When and where was the garment purchased?
_______________________________________________________________________________

(5175-5274)

_______________________________________________________________________________

Q.79 Had the garment ever been dry cleaned prior to the incident?
(5275)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 81]

Q.80 About how many times had the garment been dry cleaned?
____________________________________________________________

(5276-5305)

Q.81 Had the garment ever been laundered/washed prior to the incident?
(5306)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 83]

Q.82 About how many times had the garment been laundered/washed?
____________________________________________________________

(5307-5336)

Q.83 Would it be possible for the CPSC to obtain the garment involved in the incident?
(5337)

q 1 Yes
q 2 No
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 87]

Q.84 Would it be alright if someone from the CPSC came to your home to pick up the garment at a
time convenient to you?
(5338)

q 1 Yes
q 2 No
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 87]

Q.85 What is the best phone number for CPSC to use to arrange a pick-up time with you?
Interviewer: If the respondent says that the phone # you reached him/her at is best, enter that phone
number here, including area code.
_______________________________________________________________________________

(5339-5388)

Q.86 Interviewer: Ask respondent to keep the garment for a month in case CPSC wishes to collect it.

Q.87 Now I'd like to ask you about the heat source in this incident.
What was the source of ignition of the clothing?
(5389-5390)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12
q 13

Candle
Open fire (camp fire, fireplace, firepit, etc.)
Fireworks
Cooking Stove - gas
Cooking Stove - wood-burning
Cooking Stove - electric
Space Heater - gas
Space Heater - wood-burning
Space Heater - electric
Space Heater - kerosene
Space Heater - other
Other
Don't Know

[IF THE ANSWER TO QUESTION 87 IS NOT 11, THEN SKIP TO QUESTION 89]

Q.88 Interviewer: Specify equipment and fuel for "Other Space Heater".
_______________________________________________________________________________

(5391-5490)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 12, THEN SKIP TO QUESTION 90]

Q.89 Interviewer: Specify "Other" ignition source.
_______________________________________________________________________________

(5491-5590)

_______________________________________________________________________________

Q.90 Were any flammable liquids involved (for example, gasoline or lighter fluid) ?
(5591)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 92]

Q.91 What type of flammable liquid and about how much?
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

(5592-5641)

Q.92 Was [victim's name] around the fireworks in connection with a job he/she was doing, such as
helping someone put on a fireworks show in your town?
(5642)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS 1, THEN SKIP TO QUESTION 102]

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.93 Was the firework involved actually a firecracker, a device intended to produce a loud noise on
the ground, but which doesn't move?
(5643)

q 1 Yes
q 2 No
q 3 Don't know
[IF THE ANSWER IS 2, THEN SKIP TO QUESTION 96]
[IF THE ANSWER IS 3, THEN SKIP TO QUESTION 98]

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.94 How would you describe the firecracker? Interviewer: Read choices.
(5644-5645)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12

An M-80
An M-500
An M-1000
A Silver Salute
A quarter stick
A half stick
A tennis ball bomb
A bird banger or rope salute
A large firecracker larger than 1/4 inch in diameter and 1.5 inches in length with no warning or brand name labeling
A small firecracker about 1/4 to 1/2 inch in diameter, sold in strips, bundles, or in bags with warning and brand name
labels
Other firecracker
Don't know
[IF THE ANSWER IS NOT 11, THEN SKIP TO QUESTION 98]

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.95 Please describe the "Other" firecracker type you indicated.
_______________________________________________________________________________

(5646-5745)

_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]
[IF THE ANSWER TO QUESTION 93 IS 1, THEN SKIP TO QUESTION 98]

Q.96 How would you describe the type of firework involved?
Interviewer: Read choices.
(5746)

q1
q2
q3
q4
q5
q6
q7
q8
q9

Roman candle - candle-shaped device that fires colored balls and makes small explosions
Rocket or bottle rocket - 1/4" to 1" diameter firework attached to the top of a stick. It flies like a missile after lighting.
Sparkler - 9" to 36" long stick that emits sparks after lighting
Pest Control or wildlife control device
"Cake" multiple tube device or multiple shot repeater - A cluster of tubes that each shoots fireworks into the air.
"Reloadable" mortar or aerial shell device - uses at least one mortar tube and at least 6 shells.
Fountain type firework - cone or cylinder which emits a shower of sparks into the air
Other
Don't Know
[IF THE ANSWER IS NOT 8, THEN SKIP TO QUESTION 98]

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.97 Please describe the "Other" firework type you indicated.
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

(5747-5846)

Q.98 Please describe the firework in as much detail as you can recall.
_______________________________________________________________________________

(5847-6096)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.99 How were the fireworks obtained? Interviewer: Read choices.
(6097)

q1
q2
q3
q4
q5
q6
q7

From a friend or relative
From a stand that only sells fireworks
From a store
Mail order
Internet
Other
Don't Know

[IF THE ANSWER IS NOT 6, THEN SKIP TO QUESTION 101]

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

Q.100 Please describe the "Other" way in which the fireworks were obtained.
_______________________________________________________________________________
_______________________________________________________________________________

[IF THE ANSWER TO QUESTION 87 IS NOT 3, THEN SKIP TO QUESTION 102]

(6098-6247)

Q.101 Please give me as many details as you can about where the fireworks were obtained,
including the name of the business and where it was located. Interviewer: Probe for at least
city and state of business.
If the fireworks were ordered online, please provide the website address.
_______________________________________________________________________________

(6248-6397)

_______________________________________________________________________________

Q.102 Where did the incident occur?
(6398-6399)

q 01
q 02
q 03
q 04
q 05
q 06
q 07
q 08
q 09
q 10
q 11
q 12

Street
Open field
Outdoor yard of a home
Outdoor porch or deck
Enclosed porch
Kitchen
Living Room
Dining Room
Bathroom
Bedroom
Other
Don't Know

[IF THE ANSWER IS NOT 11, THEN SKIP TO QUESTION 104]

Q.103 Specify "Other" location of incident.
_______________________________________________________________________________
_______________________________________________________________________________

(6400-6499)

Q.104 What was the town/city and state where the incident occurred?
_______________________________________________________________________________

(6500-6599)

_______________________________________________________________________________

Q.105 At what time of day did the incident occur?
Interviewer: Enter approximate time, including AM or PM.
__________________________________________________

(6600-6624)

[IF THE ANSWER TO QUESTION 10 IS 2, THEN SKIP TO QUESTION 107]

Q.106 You mentioned earlier that you did witness the incident. Did anyone else witness the
incident besides you?
(6625)

q 1 Yes
q 2 No
[IF THE ANSWER TO QUESTION 10 IS 1, THEN SKIP TO QUESTION 108]

Q.107 You mentioned earlier that you did not witness the incident. From what you know, did
anyone witness the incident?
(6626)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER TO QUESTION 106 IS 2, THEN SKIP TO QUESTION 109]
[IF THE ANSWER TO QUESTION 107 IS 2-3, THEN SKIP TO QUESTION 109]

Q.108 Please describe their relationship to [victim's name] and their age(s).
_______________________________________________________________________________

(6627-6726)

_______________________________________________________________________________

Q.109 Did the fire department arrive at the incident?
(6727)

q 1 Yes
q 2 No
q 3 Don't Know
[IF THE ANSWER IS NOT 1, THEN SKIP TO QUESTION 111]

Q.110 If you can, please tell me the name of the fire department.
_______________________________________________________________________________

(6728-6827)

_______________________________________________________________________________

Q.111 These final questions concerning race and ethnicity help the CPSC better focus its outreach
and education efforts related to children's safety.

Q.112 Is [victim's name] of Hispanic, Latino, or Spanish origin?
Interviewer: If respondent hesitates or initially responds "Don't Know", prompt with the following
explanation: This definition of Hispanic includes people from, or descended from, Spain, Mexico,
Puerto Rico, Cuba, The Dominican Republic, or Central or South America, regardless of race.
(6828)

q1
q2
q3
q4

Yes
No
Refused to answer
Don't Know

Q.113 Which of the following races describe [victim's name] ? Please tell me all that apply.
Interviewer: Read choices and enter all that apply.
(6829-6834)

q1
q2
q3
q4
q5
q6
q7
q8

White or Caucasion
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
Native American or Alaska Native
Other
Refused to answer
Don't Know

[IF THE ANSWER IS NOT 6, THEN SKIP TO QUESTION 115]

Q.114 Please tell me the "Other" race(s) that applies.
_______________________________________________________________________________
_______________________________________________________________________________

Q.115 Thank you very much for your time.

Q.116 Interviewer: Please enter the interview completion date in the form of mm/dd/yyyy.
____________________

(6935-6944)

Q.117 Date
__________________

(6945-6953)

Q.118 Duration
____________

(6954-6959)

(6835-6934)

Q.119 Interviewer
________

(6960-6963)

[IF THE ANSWER TO QUESTION 5 IS 1 OR 2, THEN SKIP TO QUESTION 121]

Q.120 Dummy question - do not ask: Calculates whether there is more than one response to Q52. If only
one response, then skip Q55.

Q.121 [End of File]

dummy

____ (3980-3981)